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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW RE,UEST FORM <br />Date March 19, 2018 <br />Department Public Works <br />Name Roger Nawrot Division/Bureau Engineering <br />BPW Date April 24, 2018 Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal Z Attorney Name: Clara McDaniels <br />Controller z Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing z <br />F_ Check the Appropriate Item Type - Required for All Submissions <br />F-1 Agreement F] Contract Ll Proposal El Addendum <br />F-1 Professional Services F-1 Resolution <br />F1 Bid Opening El Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />F-1 Quote Opening 0 Quote Award <br />❑ Change Order No. F-1 C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />F-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source. <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />uired Information <br />El Yes E] No E:1 If Yes, Approved by <br />Purchasing <br />El MBE F-1 WBE <br />F-1 No 0 Yes Name of Company <br />Colfax Avenue Two -Way Conversion <br />- <br />115-05 3A <br />West Washington Develo meat Area TIF <br />422. 1 a5o.460.a2. <br />$ <br />Not to Exceed ff <br />H Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, IE-Verify, Iran, etc.) <br />Amount of H Increase $ <br />El Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % V&D <br />New Amount works <br />Total Percent of Change. % MAR 2 7 m <br />Dispersal After Approval 'Ie � *'7_'71 <br />Copy Original <br />E F❑I Chris Dressel <br />❑ El <br />El El <br />