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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 5/6/2019 Department Public Works <br />..................................................................................m........�..m................................ �w a ....... <br />Name Becca Plantz Division/Bureau Engineering <br />BPW Date 5/14/2....... _.._ .... ..�.. �_... .... ..._�___.�... m m.... <br />019 Phone Extension 5998 <br />mumuimuiuuuuuuuuuuuuuuuuuumuwiuiuiuiuiuimwuuuuwwuwi oannm�mmmmam aa^rrr�mim uu M rmruaru�iu mi�� mmmmmNN <br />....... _.. .......�_..�..__. � Board <br />....... ............w R uired Prior to Submittal to _........_�.._._.......... ���-........ <br />Legal ❑ Attorney Name: <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 />�} Agreement Amendment <br />Professional Services <br />[ Bid Opening <br />[l Quote Opening <br />® Change Order No. 1 <br />El Ease/Encroach. <br />F Other: <br />Topriate Item T ype — <br />[l Contract <br />[] Resolution <br />El Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control: <br />for All Submissions <br />U Proposal <br />ElReq. to Advertise <br />Required Information <br />El PCA <br />Addendum <br />❑ Title Sheet <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non Discrimination, Non -Debarment E-Verify9 Iran, etc. <br />Reguired For Change Orders O n Lea <br />„_ _.._._._......._.........��. <br />Amount of Increase <br />n ee se $ 243.52 <br />......... _ �..�.A...,_...................................�................. <br />Previous Amount $ 104,000.00 <br />, � 0.2............. <br />Current Percent of Change: .......................... m.��.�............................................�.�.��.�.�.�.�.�.�.� .,.�,�,,,� ........... <br />23% <br />New Amount $ 104,2.m................ <br />43.52 <br />Total Percent of Change: 0 23 /o <br />0 <br />Dispersal After ADoroval <br />Copy <br />Original <br />❑ <br />F] <br />