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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 817118 <br />Purchasing ❑ <br />❑ Agreement <br />❑ Contract j] Proposal U Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />® Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />f lOther: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBEIWBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Premier 1 Construciton, Inc. <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />F] MBE F-1 WBE <br />Ziker Sample Street Building: Restroom Remodel <br />117--123 <br />River West TIF <br />324-1050-460-42.02 <br />$ 23,760 <br />Division C <br />Bathroom Remodel <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment, E-Verify, Iran, etc. <br />Amount of ❑ 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 <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />