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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 02/06/2017 Department <br />Name Rich Estes Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 02/14/2017 Phone Extension 5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <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 />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: <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 />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />Patrick Kerr <br />Qasim <br />Required Information <br />DLZ Indiana, LLC. <br />❑ Yes ® No ❑ If Yes, Approved by Purct <br />❑ MBE ❑ WBE <br />No ❑ Yes Name of Company <br />Sheridan Street Improvements — Phase II — <br />116-127 <br />RWDA TI <br />324-1050- <br />Not To E <br />Survey of approximately 400''of the northern side of sample <br />street at the intersection of Sheridan, and 50' of Sheridan north <br />of Sample. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Orders <br />After Approval <br />