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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />June 17, 2019 <br />Roqer Nawrot <br />Department Public Works <br />BPW Date June 25,2019 Phone Extension 5932 <br />rm .�,wm;auun wwayssrw,w,wam MMMMmmmm ice.... 000000mmMuu I -WOM <br />_..........._....__. ReNrd Prior to Submittal to ��_..._ <br />Board <br />Legal F-1 Attorney Name <br />Controller Controller review is required for all Contracts $5,000.00 or more anc <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the <br />I I 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 />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />um no r1mi <br />rro riate Item Te - <br />�] Contract <br />Resolution <br />El Bid Award <br />D Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />for All mSubmissions <br />p Addmen_ <br />Pro osal dum <br />® Req. to Advertise ® Title Sheet <br />Required Information <br />Yes LJ No <br />MBE .. .......................— <br />WBE <br />❑ PCA <br />If Yes, Approved by Purchasi <br />0 No ❑ YesNameof Company <br />-Wayne Street & Leighton Plaza Parkin <br />�Way „ g m e ,mac Structures Repairs 2019 <br />119-048 <br />Parking Garage Fundmm . <br />Wayne-601 0464-645 36 01 Leighton 601-0462mm645.36-01 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Nora -Debarment, E- Verify, Iran, etc. <br />El increase n <br />R Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />% <br />Dispersal After p Approva <br />