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Date <br />Name <br />11-1-16 <br />Corbitt Kerr <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 11-08-16 Phone Extension 5931 <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 ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />R <br />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 ❑ Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Chance: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />J WBE <br />Yes Name of C <br />hole and Sewer <br />11 <br />Utility Expense / Contractual Service — Other <br />641-0621-792.63-35 <br />NTB — 11/15, Advertise (I1/18. 11/25) <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />squired For Chance Orders Onlv <br />After <br />Works <br />