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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 15, 2016 <br />Name Michael Divita Department DCI <br />BPW Date December 22, 2016 Phone Extension 5843 <br />Legal M <br />Controller El <br />Purchasing ❑ <br />Attorney Name Michael Schmidt <br />review is required for all Contracts $5,000.00 or more and <br />greater <br />greater than one year in length per the City Purchasing Policy <br />C qQ ',thr ApprogriaYe;)t <br />ria.7yp R quired`forq/1;Sub, misston ".. . <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />® <br />Other: Authorization for <br />Entry <br />and Temp Use <br />Company or Vendor Name <br />Susana Lagunas <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBEANBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Authorization for Entry Upon and the Temporary Use of Public <br />Property — allows sidewalk/stairway access at 1302-08 Western <br />Avenue for business development at 1312 Western Avenue <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment E-Verify Iran, etc.) <br />❑ Increase $ <br />Amount of <br />❑ Decrease <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Chanqe: <br />% <br />Copy <br />Origina <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Michael Divita, DC] <br />