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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />December 16th, 2016 <br />Kevin Fink <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date December 22"d, 2016 Phone Extension 5903 <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 />❑ <br />Agreement <br />❑ Contract ❑ 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. <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 ❑ Increase <br />R Decrease <br />Previous Amount <br />Inc. <br />A If Yes, Approved by Purchasi <br />❑ No ❑ Yes Name of Company <br />County -City Building Van Accessible Parking <br />116-038 <br />LRSA <br />251-0608-431.36-10 <br />$16,296.00 <br />Unit Prices not to exceed <br />Construction of a van -accessible on -street parking spot at the <br />intersection of Jefferson and Lafayette <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />squired F�ir,.Changd Orders;C7ta(y,,, - ;; <br />Current Percent of Change: % <br />New Amount $ <br />® ❑ Roger Nawrot <br />® ❑ Kevin Fink <br />❑ ❑ <br />