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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 2� 2018 <br />Name Aladean DeRose <br />Department Legal <br />Division/Bureau <br />BPW Date January 10, 2018 Phone Extension 5866 <br />.. . . . ................... ---- ------- . ... ......... ....... ............ .. ............ <br />Reguired Prior to Submittal to Board . . . . ............. <br />Legal Attorney Name: Aladean DeRose <br />Controller El 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 <br />[__] Agreement Amendment <br />El Professional Services <br />F1 Bid Opening <br />El Quote Opening <br />El Change Order No. <br />Ease/Encroach. <br />Other: _PCkr614 CA (�C­AiZ4 Oc:r- <br />Company or Vendor Name <br />iropriate Item Type — Required for All Submissions <br />Contract Proposal Addendum <br />FA Resolution 11"rove-AbA <br />Bid Award Req. to Advertise El Title Sheet <br />pl V) <br />El Quote Awar A <br />ir "Y <br />F] C/O & PCA Nome--- - E]PCA <br />F Traffic Control: <br />New Vendor <br />MBENVBE Contractor <br />MBENVBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />uired Information <br />N/A <br />F Yes n No El If Yes, Approved by <br />Purchasina <br />.MBE LJ WBE <br />No"_'M —Yes Name of Co <br />Terms of Contract <br />'36 <br />Purpose/Description A A4 1-4 �rrn_e- - <br />'�'u J� <br />Reii:ll �ired Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />�qu�ird For Charge Orders <br />Amount of increase ---------- <br />F-1 Decrease <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount <br />.................... <br />Total Percent of Change: % <br />............. Dispersal After .?Approval <br />Copy Original <br />F-1 F-1 <br />El 0 <br />F-1 El <br />