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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date April 29, 2019 <br />Department Public Works <br />Name Roger Nawrot Division/Bureau Engineering <br />.................... <br />B PW Date �a.......... .............. �........... � m..._......� <br />4, 2019 Phone Extension 5932 <br />armwwwwwuwuur w�vv�u mmmmomimimuumwmmuuuuuuummmiu ilimim r(AMrr � mmmimi�m�mmmmmmmmumuu ur... mwmwm mmm�00000000000mmmmmmmm m'munl mommw,rvmemmimmuuuuuuuuuuuuuuuummuwmi <br />[ --.. �. <br />Rtuired Prior to Submittal to Board <br />...._. ._ ........... w �_.m_..� ._ ........ — <br />Legal F-1 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 E <br />_ ........................Check the <br />�j Agreement <br />Professional Services <br />Bid Opening <br />❑ Quote Opening <br />�] Change Order No. <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />)ropriate Item Type — <br />F] Contract <br />El Resolution <br />�] Bid Award <br />Quote Award <br />❑ C/O & PCA No. _ <br />❑ Traffic Control: <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 />for All Submissions <br />I Proposal <br />❑ Req. to Advertise <br />Required mm Information <br />Earth Exploration, Inc. <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Yes IjNO If Yes,,App ?v9 Purchasing <br />[� MBE WBE <br />0.,No Yes Name of Company <br />Main & Colfax Parking Garage <br />115-143A <br />Parking Garage - Repairs and Maintenance <br />601.0460.645.36.01 <br />Not-to._.�E�xce�ed..�.�.�.........._ .. ����...m..m..m................ ,���.� .�..._�. <br />Thisagreement is for the concrete test' <br />R .. .. _ � -during construction. <br />Required Contractors Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Change Orders On <br />Amount of Increase $ <br />0 Decrease $ <br />Previous Amount <br />Current Percent of Change:_ <br />New Amount <br />Total Percent of Change: <br />Dispersal After Aooroval <br />Copy Original <br />® ❑ Roger Nawrot <br />F ❑ <br />E] ❑ <br />