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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 7, 2017 <br />Roger Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date March 14, 2017 Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <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 Amendment ❑ 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 />n Other: <br />uired Information <br />Company or Vendor Name <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />New Vendor Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <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 />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of <br />Centennial Parking Garage Sight Distance <br />TR17-004. TR17-032 <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />uired For Change Orders <br />% <br />Copy <br />Original <br />® <br />❑ Roger Nawr <br />® <br />❑ Ed Gleckler <br />® <br />❑ SBPD <br />After Approval <br />Assistant City Engineer <br />er Bureau of Traffic & Li <br />