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Date <br />Name <br />2/6/18 <br />Kyle Silveus <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 2/13/2018 Phone Extension 9083 <br />U <br />Agreement <br />U Contract U Proposal U Addendum <br />® <br />Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />�I <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBENVBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Jones Petrie Rafinski (JPR) <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />St. Joseph Streetsca e <br />118-008 <br />SOUTH SIDE DEVELOPMENT TIF <br />430-1050-460-31 -02 <br />$43,050.00 <br />Design and Plan Preparation for St. Joe Street roadway <br />improvements from Ireland Rd. to Callander St. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of ❑ 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 <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />