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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 4, 2018 <br />Name Kyle Silyeus Department —Engineering <br />BPW Date Septerrrber 11, 2018 Phone Extension 9083 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing El <br />Check the Appropriate Item Type — Required for ill Subrraissions <br />[:1 Agreement El Contract El Proposal ❑ Addendum <br />F-1 Professional Services n Resolution <br />F-1 Bid Opening n Bid Award Z Req. to Advertise Title Sheet <br />F] Quote Opening ❑ Quote Award <br />F] Change Order No. ❑ C/O & PCA No. F1 PCA <br />E] Ease/Encroach, Traffic Control <br />F-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />uired Information <br />TBD <br />Yes [:1 No ❑ If Yes, Approved by Purchasing <br />MBE [_1 WBE <br />Lafayette Building Skylight & Masonry Repairs <br />117-IOOR <br />RWDA <br />324-1050-460-42,02 <br />$ TBD <br />Terms of Contract Base Bid plus Alternates <br />Purpose/Description Skylight and Masonry Repairs to Lafayette Building <br />F-1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, iran, etc.,--. <br />Required For Chanqe Orders Only <br />Amount of R increase $ <br />El Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % AY VID <br />Behad ?5f <br />Dispersal After Approval <br />Copy <br />Original <br />1:1 <br />n <br />F-1 <br />F1 <br />1:1 <br />El <br />