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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />3/20/17 <br />Department <br />Public Works <br />Name <br />Corbitt Kerr <br />Division/Bureau <br />Engineering <br />BPW Date <br />3/28/17 <br />Phone Extension <br />5931 <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name: Michael Schmidt <br />Controller ❑ <br />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 />red Information <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No ❑ If <br />MBE/WBE Contractor LJ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Nar <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 />Deere; <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Western Avenue Corridor Improvements from Bendix Drive to <br />Olive Street <br />115-097 (16JW01) <br />RWDA TIF <br />324-1050-460-42.03 <br />Advertise 3/31 and 4/7 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />=auired For Chanae Orders Onlv <br />r ADD rova <br />