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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />October 3, 2017 <br />Jacob M. Klosinski <br />Purchasing <br />® Carol Kurzhal <br />Department Utilities - Wastewater <br />❑ Agreement ❑ 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 />Company or Vendor Name <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Proiect Name Farminaton 14A Lift Station Rehabilitation <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />117-027 <br />Utilities, Wastewater Capital <br />642-0630-415-43-66 <br />IN <br />Purpose/Description Request approval of Title Sheet and ,Request to Advertise for <br />Project No. 117-027 Farmin ton Lift Station 14A Rehabilitation. <br />Refer to Inter -Office Memorandum attached. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc.) <br />Amount of 0 <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 />® ❑ Al Greek, Director of Utilities <br />® ❑ Jacob M. Klosinski, Assistant City Engineer <br />® ❑ Carol Kurzhal, Director of Financial Services, Environmental Services <br />