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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 3, 2017 <br />Name Michael Divita`0_ Department DCI <br />BPW Date November 14, 2017 Phone Extension 5843 <br />Legal Attorney Name Aladean DeRose .. ... ,: <br />. � Y <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 />LJ Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />❑ Other: <br />L_J Contract <br />® Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O &PCANo. <br />❑ Traffic Control <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor ❑ MBE ❑ WBE <br />MBEIWBE 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 Adoption of a Fiscal Plan for the Baney Annexation Area <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non Discrimination, .Non -Debarment, E Verif MEEIran, etc. <br />Amount of increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />Investment <br />