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BOARD OF PUBLIC WORKS <br />AGENDA ITEM RE VIEW REQUEST FORM <br />Date Jul _12, 2018 <br />Name Roger Nawrot Department Engineering <br />BPW Date July_24, 2018 Phone Extension 5932 <br />Required Prier 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 <br />LJ Agreement <br />H Contract <br />H Proposal ❑Addendum <br />N Professional Services <br />El Resolution <br />F-1 Bid Opening <br />F] Bid Award <br />❑ Req. to Advertise 0 Title Sheet <br />F-1 Quote Opening <br />F] Quote Award <br />[ ] Change Order No. <br />M C/O & PCA No. <br />❑ PCA <br />El Ease/Encroach. <br />El Traffic Control <br />F-1 Other-, <br />kegt4ireO Information <br />Company or Vendor Name <br />Lawson -Fisher Associates P.C. <br />El Yes H No <br />El If Yes, Approved by <br />New Vendor <br />Purchasing__ <br />MBEA/VBE Contractor <br />[:]' MBE [:] WBE <br />MBEAA[BE Contractor Requested [:]! No [:] Yes Name of Compa <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Corby Blvd. -Ironwood Dr.-Rockne Dr. Real Estate Services <br />116-034A <br />r Moves <br />412-0602-431.42-03 <br />$87,000.00 <br />NTE <br />F-1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders, brily <br />Amount of F1 increase $ <br />El Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />F-1 <br />❑ <br />alp <br />