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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12-16-2016 <br />Name Amy O'Connor Department <br />Admin & Finance <br />BPW Date 12-27-2016 Phone Extension 9133 <br />Required Prior to Submittal to Board <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 />Agreement Contract ❑ Proposal ❑ Addendum <br />Professional Services Resolution,* Lfl'2-tAq <br />Bid Opening Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />Quote Opening ❑ Quote Award <br />Change Order No. ❑ C/O & PCA No. ❑ PCA <br />Ease/Encroach. ❑ Traffic Control <br />Other: Waste Water Asset <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount $ <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verif , Iran, etc. <br />Required For Change Orders OnlyOrders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />❑ ® Am,, <br />O'Connor <br />of Admin & Finance, 12th Floor County -City Build <br />® ❑ Carol Kurzhal, Waste Water, Riverside <br />❑ ❑ <br />