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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />1/30/2017 <br />Department Public Works <br />BPW Date 2/14/2017 Phone Extension 5961 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Hanako Parkhill <br />Purchasing ❑ <br />I Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement <br />❑ Contract <br />❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Ease./Encroach. <br />❑ Traffic Control <br />❑ Resolution <br />® Other: Exempt. Approval <br />❑ Claim <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <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 />Brian Beck <br />EI-Yes <br />❑ No <br />❑ MBE <br />I -I WBE <br />ired <br />If Yes, Ap <br />by Nurchasing <br />Completed E-Verify Form Attached ❑ Yes <br />❑ No <br />Downspout Disconnect Exemption Approval <br />NA <br />NA <br />NA <br />Approve a special exemption from mandatory downspout disconnect. <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />PO No. <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />7 <br />❑ <br />For Change Orders <br />Dispersal After Approval <br />Hanako Parkhill <br />Kieran <br />