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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date January 3, 2017 Department <br />Name Tara Weigand Division/Bureau <br />Public Works <br />Engineering <br />BPW Date January 10, 2017 Phone Extension 5998 <br />to Submittal to <br />Legal ❑ <br />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 ❑ Pro <br />❑ <br />Professional Services <br />osal <br />p ❑Addendum <br />❑ Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award <br />❑ Quote Award ElReq. to Advertise ❑Title Sheet <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />® Traffic Control: <br />❑ <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 />nformation <br />❑ Yes ❑ No ❑ If Yes, Angroved by <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Roger Nawrot, Assistant City Engineer <br />® ❑ Ed Gleckler, Manager Bureau of Traffic & Lighting <br />® ❑ SBPD <br />