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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 20, 2016 <br />Department <br />Public Works <br />Name <br />Corbitt Kerr <br />Division/Bureau <br />Engineering <br />BPW Date <br />February 28, 2016 <br />Phone Extension <br />5931 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael 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 />Required Information <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 uIncrease <br />❑ <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Origin. <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />DLZ <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />J WBE <br />Yes Name of <br />Colfax Avenue Two -Way Conversion <br />115-053 <br />West Washington Development Area TIF <br />422.1050.460.42.03 <br />$215,250.00 <br />Not to Exceed <br />Provide services for the design of Cemetery Entrance, Colfax <br />2way Conversion, and Improvements to Elm and LaSalle. <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />�auired For Change Orders Only <br />Chris Dressel <br />Dispersal After <br />