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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />June 30, 2017 <br />Roger T. Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date July 11, 2017 Phone Extension 5932 <br />L J <br />Agreement <br />Ll Contract Ll Proposal U Addendum <br />® <br />Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />I-1 <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 />Amount of <br />Abonmarche Consultants, Inc. <br />❑ Yes ® No ❑If Yes <br />❑ MBEEI WBE <br />❑ No ❑ Yes Name of Company <br />Beck's lake Outlet Control Valve Survf <br />117-079 <br />Professional Services <br />Purchasin <br />$6,200.00 <br />Not to Exceed <br />Field Survey to obtain elevations for all of the inlet and outlet <br />pipes and the downstream receiving sewer. <br />�..,J Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />