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Date <br />Name <br />BP W Date <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 5, 2018 <br />Roger T. Nawrot <br />March 13, 2018 <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal Z Attorney Name: Michael Schmidt <br />Controller z 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 z <br />Check the <br />LJ'Agreement <br />F-1 Professional Services <br />❑ Bid Opening <br />Quote Opening <br />Change Order No. <br />El Ease/Encroach. <br />R Other: <br />Company or Vendor Name <br />iropriate Item Type — <br />Ell Contract <br />El Resolution <br />[:] Bid Award <br />F-1 Quote Award <br />El C/O & PCA No. <br />El Traffic Control: <br />for.All Submissions <br />I Proposal <br />Z Req. to Advertise <br />aired Information <br />NMI <br />FA <br />Vr4M_T a ql"'" <br />._ 11 <br />E] Title Sheet <br />El Yes Z No If Yes, Approved by <br />New Vendor Purchasing <br />MBEANBE Contractor [:] MBE [J WBE <br />MBEANBE Contractor Requested E No [:] Yes Name of Company <br />Project Name Tucker Drive <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />11 6-118A <br />RWTD <br />324-1050-460.3102 <br />Bids to be taken at the April 10 meeting. <br />F1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />F1 Increase $ "eard of pfrIJ 7Amount of F-1 Decrease $ U4, <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chanae: % <br />Copy <br />Original <br />F-1 <br />R <br />F-1 <br />F-1 <br />El <br />El <br />I <br />