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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />01 /17/2017 <br />Roger Nawrot <br />Department Engineering <br />Division/Bureau Public Works <br />BPW Date 01/24/2017 Phone Extension <br />I Required Prior to Submittal to Board <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 AN Submissions <br />❑ <br />Agreement Amendment <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: Street Name Changes <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 />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chance: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Information <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasina <br />MBE LJ W <br />No ❑ Yes <br />St. Joseph Street from Western Avenue to Marion Street to Dr. <br />Martin Luther King, Junior Boulevard. <br />Dr. Martin Luther King, Jr. Drive to Charles Martin, Senior Drive. <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Change Orders <br />