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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date January 12, 2018 <br />Name Roger Nawrot <br />BPW Date January 23, 2018 <br />Department Public Works <br />Division/Bureau Engineering <br />Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal <br />Attorney Name: <br />Controller <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in <br />length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Required <br />forAll Submissions <br />El Agreement <br />El Contract <br />El Proposal El Addendum <br />EJ Professional Services <br />F1 Resolution <br />E] Bid Opening <br />El Bid Award <br />M Req. to Advertise Title Sheet <br />El Quote Opening <br />El Quote Award <br />0 Change Order No. <br />P C/O & PCA No. <br />F-1 PCA <br />❑ Ease/Encroach. <br />F-1 Traffic Control: <br />F-1 Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />El Yes El No El If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />[:1 MBE [:1 WBE <br />MBEANBE Contractor Requested <br />E] No E] Yes Name of Company <br />Project Name <br />Ironwood Drive Pavement Rehabilitation <br />Project Number <br />117-071 <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Advertisement for bids on February 9 & 16 with bids received on <br />February 27. <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non-Discrjmination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of F-1 increase <br />R Decrease <br />$ <br />$ <br />Previous Amount $ <br />API)ROVUD <br />Current Percent of Change-, <br />% (if ni WW'ks <br />New Amount $ <br />I A k 11 C) Q .'1 4 11 <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />Kara Boyles <br />El <br />El R <br />