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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />11/17/2016 <br />Public Works <br />Engineering <br />BPW Date 11/22/2016 Phone Extension 5896 <br />Richard Estes <br />Department <br />Division/Bureau <br />Legal Attorney Name: Michael Schmidt <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 ® George King <br />Check the Appro <br />riate Item Type — Required for Ali Submissions <br />❑ <br />Agreement <br />Contract EJ Proposal Addendum <br />❑ <br />Professional Services ❑ <br />Resolution <br />❑ <br />Bid Opening ❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ <br />Quote Award <br />® <br />Change Order No. 3 ❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ <br />Traffic Control: <br />F1 <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 />Builders <br />No LJ If Yes, Approved by <br />116-021 <br />RW DA TIF <br />324-1050-460-3102 <br />$1,267.49 <br />Reflects additional slab and water main work, reimbursement of <br />permit fees, payment for an unused manhole structure due to <br />design change, and remaining balance on over/under runs <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of ZI Increase _ <br />❑ Decrease <br />Previous Amount $ 81 <br />Current Percent of Change: 0.17 <br />New Amount <br />Total Percent of <br />py <br />Original <br />�1 <br />■ <br />// <br />■ <br />ired For I <br />1.267.49 <br />Patrick C. Kerr, Jitin Kain <br />Matt Flick, Majority Builders <br />