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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/6/18 <br />Department Public Works <br />Name Sue Ellen Doudrick Division/Bureau Engineering <br />.�.._............_..................... �� �. .....�..��.�..�..�_._ .................w <br />�................... <br />BPW Date 11/13/18 Phone Extension 5992 <br />Required Prior to Submittal to Board <br />LegalAttorney <br />Name: Clara McDaniels <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Michael Schmidt <br />Check them <br />Hate Item "hype — Requiredfor All Submissions <br />Agreement Amendment <br />FC <br />ontract �Proposal Addendum <br />El <br />Professional Services <br />n <br />Resolution <br />El <br />Bid Opening <br />n <br />Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ Change Order No. <br />❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control: <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Original <br />F-1 <br />El <br />0 <br />El <br />red Information <br />Yes No ❑mmmmlf Yes, Approved by <br />Purchasin <br />MBE WBE <br />.... <br />Yes Name m <br />No of Companwy� <br />Sewer and Manhole Rehabilitation <br />118-093 .................. ____ Y .�............. <br />. <br />Utilitv Expense/Contractual Service <br />641-0621-792.63-35 <br />Sewer & Manhole Rehabilitation for 1) CSO 018 Network from <br />Dale to River, 2) Diamond/Angela from Lincoln Way to River, 3) <br />and other various sewer and manhole locations <br />Required Contractor's Certification Forms At q � tached (Non <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />.._ <br />uired For Orders Chan e OrdeOnl"' <br />g _ ...... ----_ ...... _... .. <br />$ .� m._._..... <br />$ <br />DismeralmAfter <br />