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BOARD OF PUBLIC WORKS <br /> AGENDA ITEM REVIEW REQUEST FORM <br /> Date December 26. , 2018 Department Legal <br /> Name Aladean DeRose Division/Bureau <br /> BPW Date January 10, 2018 Phone Extension 5866 <br /> Required Prior to Submittal to Board <br /> Legal [l Attorney Name: Aladean DeRose <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 /> I Check the Appropriate Item Type- Required for All Submissions <br /> ❑ Agreement Amendment ❑ Contract C Proposal I ] Addendum <br /> ❑ Professional Services El Resolution pnravc-AM/\ <br /> n Bid Opening ❑ Bid Award ie >a P1 Req. to Advertise I 1 Title Sheet <br /> pian <br /> ❑ Quote Opening n Quote Awar 10�� I�6J AeeCk ny f <br /> ❑ Change Order No. ❑ C/O & PCA o.- ❑ PCA <br /> El Ease/Encroach. , Traffic Control: <br /> CK Other:'inti G [(C,%R-t. 'J <br /> Required Information <br /> Company or Vendor Name N/A <br /> ❑ Yes ❑ No ❑ If Yes, Approved by <br /> New Vendor Purchasing <br /> MBE/WBE Contractor I I MBE ❑ WBE <br /> MBE/WBE Contractor Requested ❑ No n Yes Name of Company <br /> Project Name <br /> Project Number <br /> Funding Source <br /> Account No. <br /> Amount <br /> Terms of Contract i)WBwc / - //J6-,�,1,c) ALL-lno,' <br /> Purpose/Description 41pwii, D4 1'�! i rim JV4A,� 4 -1772.c...21 ?LAI <br /> .� Required Contractor's Certification Forms Attached (Non- <br /> Collusion, Non-Discrimination, Non-Debarment, E-Verify, Iran, etc.) <br /> 1 Required For Change Orders Only <br /> Amount of Increase $ <br /> I 1 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 /> II II <br /> H <br /> II <br />