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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />8/7/18 <br />Derick RobertslTerri Swift <br />Department PWIStreets <br />BPW Date Phone Extension 7567 <br />® Agreement <br />❑ Contract U Proposal LJ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />CIO & PCA No. ❑PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ Other: <br />Required Information <br />Company or Vendor Name <br />RoadBotics <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBEIWBE Contractor <br />Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />2018 Road Surface Condition Assessment <br />Project Number <br />Funding Source <br />MVH <br />Account No. <br />202-0607-431.31-06 <br />Amount <br />33,000.00 <br />Terms of Contract <br />Purpose/Description <br />To provide additional assessment tool for road surface condition — <br />Pilot Program <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required ForChange Orders Only <br />Amount of ❑ <br />❑ <br />Increase $ <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />Roger Nawrot <br />❑ ❑ <br />Tara Wiegand <br />❑ ❑ <br />Terri Swift <br />