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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />0 1 001IM1 U-6 <br />Alicia Czarnecki <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 06/12/2018 Phone Extension 5903 <br />. . . .... ... <br />Required Prior to Submittal to Board <br />Legal El Attorney Name: Clara McDaniels <br />Controller El 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 1:1 <br />Check the Appropriate Item Type — Required for AH Submissions <br />El Agreement Amendment P Contract El Proposal F1 Addendum <br />F-1 Professional Services El Resolution <br />❑I Bid Opening El Bid Award M Req. to Advertise E:1 Title Sheet <br />F-1 Quote Opening F-1 Quote Award <br />❑ Change Order No. F] C/O & PCA No.. ❑ PCA <br />Ease/Encroach. ❑ Traffic Control: <br />❑ Other: General Release Required Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEAA1BE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />TBD <br />El Yes E] No F-1 If Yes, Approved by <br />Purchasing <br />[:] MBE [:] WBE <br />n No El Yes Name of Company <br />Ravina Park — Bank Stabilization <br />11 7-073A <br />El Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of 0 increase $ A fl-"W(ND <br />F-1 Decrease <br />Previous Amount $ <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />% bmw 1: - <br />Dispersal After Approval <br />Copy <br />Original <br />M <br />F-1 Kara Boyles, City Engineer <br />E <br />E] Alicia Czarnecki <br />F <br />El <br />