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BOARD OF PUBLIC WORDS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />10/02/18 <br />Becca Plantz <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 10/09/18 Phone Extension 5998 <br />Re' u�red Prior 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 ❑ Michael Schmidt <br />N <br />Agreement Amendment <br />Ll Contract Ll Proposal U Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Patrick Engineering <br />❑ Yes ❑No <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Corn <br />West Side Quiet Zone <br />117-114 <br />If Yes, Approved by <br />50% LRSA & 50 % Engineering_Professional Services <br />50% to 251-0608-431.23-02, 50% to 101 -0608-431.3106 <br />Amendment Total $25,000 (New Total * Original PSA=$53,500) <br />NTE <br />Assess the required improvements and associated costs to re- <br />open East Side Quiet Zone alleyways _ <br />❑ Required Contractor's Certification Forms 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 Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />