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Date <br />Name <br />BPW Date <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />February 21, 2017 Department <br />Roger Nawrot Division/Bureau <br />February 28, 2017 <br />Public Works <br />Engineering <br />Phone Extension 5933 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <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 />U Professional Services U 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 />❑ Yes ® No ❑ If Yes, Approved by <br />Purchasinq <br />I MBE LJ WBE <br />No Yes Name of Company <br />Burnett Dr. and Ireland Rd. Stop <br />TR16-135 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Chanae Orders On <br />Amount of H Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chance: % <br />Copy Original <br />® ❑ Roger Nawrot, Assistant City Engineer <br />® ❑ Ed Gleckler, Manager Bureau of Traffic & Lighting <br />® ❑ SBPD <br />