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Date <br />Name <br />3/6/17 <br />Corbitt Kerr <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 3/14/17 Phone Extension 5931 <br />Re uired 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 />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ 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 />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 />!red I <br />❑ Yes ❑ No ❑ If Yes Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Com any <br />Berlin Place BP#2: MEP <br />117-048 <br />RWDA TIF <br />324-1050-460-3102 <br />Berlin Place MEP Improvements <br />Advertise 3124 and 3/31 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Chance Orders Onlv I <br />Amount of <br />Increase <br />Decrease <br />Previous Amount $ errauvf`ry <br />Current Percent of Change: % is or <br />New Amount <br />u <br />Fj <br />t <br />