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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />December 14, 2016 <br />Department <br />Public Works <br />Name <br />Roger T. Nawrot <br />Division/Bureau <br />Engineering <br />BPW Date <br />December 22. 2016 <br />Phone Extension <br />5932 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <br />Controller ❑ <br />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 />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <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: Residential Handicapped Parking Request <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 />❑ Yes ® No ❑ If Yes, Approved by <br />Purchasing <br />U MBE U WBE <br />❑ No ❑ Yes Name of Companv <br />934 20th Street <br />Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders 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 <br />Original <br />❑ <br />❑ Engineering - Roger Nawrot <br />❑ <br />❑ Traffic & Lighting— Ed Gleckler <br />❑ <br />❑ SB Police Dept. — Eugene Eyster <br />