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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 16, 2018 <br />Name Alicia Czarnecki <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date November 27, 2018 Phone Extension 5903 <br />HIM9®/AMID,CMIIIIIIIIIIIIIIIIIIIIIIImImIfg MElliIIIIIIIIIIIIW1wmj <br />Required 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 <br />Check the <br />LJ Agreement Amendment <br />® Professional Services <br />El Bid Opening <br />EI Quote Opening <br />El Change Order No. <br />El Ease/Encroach. <br />F-1 Other: <br />iro riate Item Type — <br />Contract <br />❑ Resolution <br />F1 Bid Award <br />n Quote Award <br />El C/O & PCA No, — <br />n Traffic Control: <br />for All Submissions <br />Proposal <br />Req. to Advertise <br />PCA <br />Addendum <br />❑ Title Sheet <br />Required Information <br />' _ Company or Vendor Name even Generations Architecture En mee Yes No ................._,_. nn LLC <br />If Yes, Approved by <br />New Vendor Purchasing, <br />��.-----. ..�.. ........... <br />l_ ...... <br />MBE/WBE Contractor FMBE 1-1 WBE <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 />Name o <br />.._ No.._. Yes ..._W_._._......... <br />f CoMpa <br />Muessel Grove Public Restroom <br />118-099 <br />VPA Capital <br />�.�...._._.------------- ........ <br />416.0404.453.36.01 <br />Lump Sum for design services; Not to Exceed <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />............................................. <br />...m................-.... �__ ..���......._. _...._..........� <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chan e: % <br />Dili <br />Copy <br />Original <br />® <br />El <br />Alicia Czarnecki. Pro <br />I After <br />Enaineer <br />Kara Boyles, City Engineer, PE <br />—.m— ,._. .........mm ... �..... .... ..... <br />Patrick Sherman, VPA Project Manager <br />