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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/19/16 <br />Name Kara M. Boyles <br />Department Engineering <br />Division/Bureau DPW <br />BPW Date 12/22/16 Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: M. 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 />U <br />Agreement <br />LJ 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 />I -I <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 />of Notre Dame <br />km <br />Purchasing <br />If Yes, <br />❑ MBE ❑ WBE <br />® No ❑ Yes Name of Company n/a <br />ND Hydroelectricity Facility at Seitz Park <br />116-XXX <br />A resolution for temporary parking on Colfax Avenue. <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 />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />