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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/01/2016 Department <br />Public Works <br />Name <br />Richard Estes <br />Division/Bureau <br />Engineering <br />BPW Date <br />11/08/2016 <br />Phone Extension <br />5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <br />Controller El greater <br />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 ❑ George King <br />Check the Appropriate Item Type — Required forAH Submissions <br />® Agreement ❑ Contract ❑ Proposal ❑ 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 />P Other: <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 LJ Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />u <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Compan <br />Notre Dame Hydro Project at Seitz Park <br />Effective until the earlier of (a) the examination is done, (b) <br />December 31, 2016 <br />Temporary Access Agreement for Notre Dame to perform Soil <br />Borings for the ND Hydro Project. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Chanae Orders <br />Patrick C Kerr, Therese Dorau <br />Aaron Perri, Paul Moreland, Brian Paulowski <br />