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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />05/15/2018 <br />Kvle Silveus <br />05122/2018 <br />Department Engineering <br />Phone Extension 5601 <br />Required Prior to Submittal to Board <br />Legal F-1 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 R Michael Schmidt <br />F-1Contract -1❑' Agreement F El Proposal El Addendum <br />F-1 Professional Services F'Resolution <br />F-1 Bid Opening E] Bid Award Req. to Advertise E] Title Sheet <br />El Quote Opening El Quote Award <br />F-1 Change Order No. F-1 C/O & PCA No, [:1 P CA <br />❑ Ease/Encroach. ❑ Traffic Control <br />Other: <br />ui:red Information <br />Company or Vendor Name TBD <br />New Vendor El Yes El No El If Yes, Approved by Purchasing <br />MBEANBE Contractor F-1 MBE n WBE <br />M'BE/WBE Contractor Requested F1 No 0 Yes Name of Company <br />Project Name LWW Charles Martin Intersection Im <br />Project Number 117-072 <br />Funding Source RWDA <br />Account No. 324-1050-460-31.02 <br />Amount $ TBD <br />Terms of Contract Base bid <br />Purpose/Description Intersection Improvements at Lincolnway West and Charles Martin <br />E:1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Re aired 1=or Chan`` e Orders C7nl <br />Amount of ❑ increase $ <br />El Decrease $ <br />Previous Amount <br />of M13; V <br />'twllc Wks <br />Current Percent of Change: % or <br />New Amount $ 9rM I d <br />Total Percent of Change: % zV <br />Dispersal After Approval <br />Copy Original <br />❑ <br />F-1 F-1 <br />11 El <br />rovements <br />