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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />►FTiT� <br />06/12/2018 <br />Alicia Czarnecki <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 06/21/2018 AR Phone Extension 5903 <br />❑ Agreement Amendment <br />U Contract U Proposal U Addendum <br />❑ Professional Services <br />❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />IRI Other: Reiect Bids <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />MBEANBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of EI <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Ravina Park <br />117-073 <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change:. % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Kara Boyles, City Engineer <br />® ❑ Alicia Czarnecki <br />❑ ❑ <br />