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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 0.6/04/18 Department Public Works <br />Name Amy Kryston Division/Bureau Engineering <br />BPW Date 06/12/18 -..-Phone Extension 9246 <br />. . .. . . . .... <br />Required Prior to Submittal to Board <br />Legal Z 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 El <br />❑ Professional Services ] Resolution <br />Bid Opening <br />El Bid Award <br />Quote Opening <br />n Quote Award <br />F-1 Change Order No. <br />E] C/O & PCA No. <br />F-1 Ease/Encroach. <br />F-1 Traffic Control: <br />M Other: Approval of Waiver <br />Application for New Utility <br />Poles & Wireless Support Structures <br />um <br />F] Title Sheet <br />Company or Vendor Name Mobilitie LLC <br />El Yes M No ❑ If Yes, Approved by <br />New Vendor Purchasing <br />MBENVBE Contractor [:] MBE [:] WBE <br />MBENVBE Contractor Requested [:] No n Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Recommend approval of the waiver application for twelve <br />locations of wireless support structures, installed by Mobilitie on <br />behalf of Sprint <br />" Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />L Re 0ired For Change ,Orders ' pjy_ <br />Amount of F-1 Increase $ <br />El Decrease $, <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />01 <br />Copy <br />Original <br />E <br />E] Kara Boyles <br />F-1 Matt Longfellow <br />F-1 Amy Kryston <br />