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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />02-28-2017 <br />Santiago Garces Department <br />Innovation <br />BPW Date 02-28-2017 Phone Extension 7652 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Schmidt <br />Controller ® 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 ❑ 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 />Reauired Information <br />Company or Vendor Name Anna Ker <br />New Vendor ® Yes [ <br />MBEM/BE Contractor ❑ MBE E <br />MBEMIBE Contractor Requested ❑ No <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 />No U If Yes, Approved by Purchasing <br />I WBE <br />Yes Name of Company <br />Services <br />5-31-06 <br />1 /1 /2017 — 2/28/2017 <br />N Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc <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 />John M <br />ired For Change Orders <br />Dispersal After Approval <br />Garces <br />