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BOARD OF PUBLIC WORKS <br />AGENDA ITEM RE, VIEW REQUEST FORM <br />Date April 30, 2018 <br />Name Roger Nawrolt <br />Department <br />Division/Bureau <br />Public Works <br />BPW Date May 8, 2018 Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal Attorney Name: Clara McDaniels <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 N <br />Check the Appropriate Item Type - Required for All Submissions <br />Agreement El Contract El Proposal _E] Addendum <br />Professional Services F-1 Resolution <br />❑ Bid Opening ❑ Bid Award Req. to Advertise E] Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />F-1 Change Order No. El C/O & PCA No.. E] PCA <br />El Ease/Encroach, El Traffic Control: <br />R Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEIWBE 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:1 No F] If Yes, Approved by <br />Purchasing_ <br />E] MBE [:1 WBE <br />El No L1 Yes Name of Company <br />Ameritech Drive Pavement Improvements <br />River West TIF <br />324-1050-460.31-20 <br />Not to Exceed <br />F] Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of LJ Increase $ APPROVID, <br />F-1 Decrease $ M—W4 Of hmic work's <br />Previous Amount <br />Current Percent of Change: % ZdAJ­T,",� 9-11 1, &S <br />New Amount <br />Total Percent of Change: <br />$ <br />% <br />I <br />Dispersal After Approval <br />Copy Original <br />El F-1 <br />F-1 F] <br />R F-1 <br />