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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />December 19, 2016 <br />Roger Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date December 22, 2016 Phone Extension 5932 <br />Legal Attorney Name: Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />ZJ< <br />Agreement <br />L_J Contract L] Proposal U Addendum <br />® <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />F] <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Increase <br />Decrease <br />Abonmarche Consultants, Inc. <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Bus Shelters As -Needed Engineering & Surveying <br />116-112 <br />$ 35,000.00 <br />Not to Exceed <br />To support the Transpo federal grant for bus shelters. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Roger Nawrot <br />Jitin Kain <br />Michael Devitta <br />