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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 14, 2016 <br />Department Public Works <br />Name Roger Nawrot Engineering Division <br />BPW Date December 22, 2016 Phone Extension 9251 <br />Legal ❑ Attorney Name <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 />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <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 />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Resolution <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />® Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control <br />Required Information <br />Instiuform Technologies USA, LLC <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Emergency Sewer Lining — Notre Dame Ave. <br />116-139 <br />Contractual Services <br />641 0621 792 6335 <br />Lining a section of leaking pipe on Notre Dame Ave. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran. etc <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Roger Nawrot, P.E. <br />Terri Swift <br />