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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />12/7/2016 <br />Jen Hockenhull Department A/F <br />BPW Date 12/13/2016 Phone Extension 9822 <br />Required Prior to Submittal to Board <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 ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ® Resolution <br />❑ Bid Opening ❑ Bid Award <br />❑ Quote O enin ElReq. to Advertise ❑Title Sheet <br />p g ❑Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Information <br />Company or Vendor Name La Casa de Amistai <br />New Vendor ❑ Yes ® No ❑ <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />If Yes, Approved by <br />MBEM/BE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name West Side Events <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Wl 1 <br />404-0617-431 <br />$10, 000.00 <br />To assist La Casa with their events which raise awareness for West <br />Side businesses and.residents <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc.) <br />I Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ John Murphy <br />❑ <br />❑ <br />❑ <br />❑ <br />