Laserfiche WebLink
BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 7, 2017 Department Public Works <br />Name Roger Nawrot Division/Bureau Engineering <br />BPW Date February 14, 2017 Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal <br />❑ Attorney Name: <br />Controller <br />review is required for all Contracts $5,000.00 or more and <br />El <br />greater <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />® Traffic Control: <br />❑ Other: <br />Required Information <br />Company or Vendor Name <br />❑ Yes ® No ❑ If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />201 William St. Handicap Parking <br />Project Number <br />TR17-002 <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <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 />Amount of ❑ <br />❑ <br />Increase $ <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />® ❑ <br />Roger Nawrot, Assistant City Engineer <br />® ❑ <br />Ed Gleckler, Manager Bureau of Traffic & Lighting <br />® ❑ <br />SBPD <br />