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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12-19-2016 <br />Name Amy O'Connor Department 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 />H Agreement L_J Contract �qd ®gyp ❑Proposal ❑Addendum <br />❑ Professional Services Resolution�AA- <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 />M Other: Disposals <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-Verifv. Iran. etc.) <br />Amount of ❑ Increa <br />❑ Decre; <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ® Amy O'Connor, Dept of Admin & Finance, 12th Floor County -City Building <br />® ❑ Captain Chris Voros, Police Dept <br />