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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/29/1 <br />Name <br />To_ Villa a <br />Department <br />Engineering <br />BPW Date <br />12/13/16 <br />Phone Extension <br />5920 <br />uired Prior to Submittal to <br />Legal L] <br />Attorney Name <br />Controller ❑ <br />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 />❑ <br />Agreement <br />Professional Services <br />❑ Contract ❑Proposal ❑ Addendum <br />❑ Resolution <br />❑ <br />El <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ❑ Req. to Advertise <br />❑ Quote Award ❑Title Sheet <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />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 />red Inform <br />U No ❑ Yes Name of Company <br />Century Center North Bridae LED Lamn Ratrnfit <br />11 <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />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 />Rich Estes <br />Tov Villa <br />ange Orders <br />Dispersal After Approval <br />