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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />October21, 2016 <br />Public Works <br />Engineering <br />BPW Date October 25, 2016 Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing El <br />Roger T. Nawrot <br />Department <br />Division/Bureau <br />Check the Appropriate Item Type — Required for AU Submissions <br />II I %yI., I I I. 1 PL u �UI ILIaci Li rroposai U Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ® Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />❑ Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chance: <br />Copy <br />Origin <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Walsh & Kelly <br />❑ Yes ®No <br />Inc. <br />404-0608-431-31-10 <br />I, 778.40 <br />to Excei <br />Yes, Approved by <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Change Orders <br />I After <br />