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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/16/2017 <br />BPW Date 3/28/2017 <br />Name Stephen Cox Fire Chief <br />Department Fire <br />Phone 9255 <br />o Legal ❑ Attorney Name <br />2 ° Co o Controller review is required for all Contracts $5,000.00 or more <br />a o E o Controller ❑ and greater than one year in length per the City Purchasing <br />( n 0 COPolicy <br />U) Purchasing ❑ <br />Check the ADorODrlate Item Tvne — Required for All Submissions <br />❑ Agreement <br />❑ Contract I <br />❑ Proposal <br />I ❑ Addendum <br />❑ Claim <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise <br />I ❑ Title Sheet <br />❑ Quote Opening <br />, Quote Award <br />❑ Chg Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Ease./Encroach. <br />❑ Traffic Control <br />❑ Resolution <br />® Other: Disposal -Unfit <br />Property <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ <br />No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor <br />MBE ❑ WBE <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Helmet and boots for retiree Steven Troy Kerckhove <br />For Change Orders Only <br />Amount of <br />❑ <br />❑ <br />Increase <br />Decrease <br />I $ <br />1 $ <br />Previous Amount <br />$ <br />Current Percent of Change. <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />PO No. <br />AC - A.-. ------ I I <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />