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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 16, 2016 <br />Department Public Works <br />Name Roger Nawrot Division/Bureau Engineering <br />BPW Date December 22, 2016 Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <br />Controller El greater <br />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 />❑ <br />Agreement LJ Contract LJ Proposal U Addendum <br />❑ <br />Professional Services ❑ Resolution <br />❑ <br />Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ Quote Award <br />❑ <br />Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ® Traffic Control: <br />F] <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE 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 />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanqe: <br />Copy <br />Original <br />® <br />❑ <br />LJ Yes N No LJ If Yes, Approved by <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />ler Nawrot, Assistant <br />Ed Gleckler, Manager Bureau of Traffic & Lighting <br />SBPD <br />