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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 30, 2019 <br />Name Roger T. Nawrot <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date October 8, 2019 Phone Extension 5932 <br />Re uired Prior to Submittal to Board <br />Legal F-1 Attorney Name: <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 D <br />Check the <br />LJ Agreement <br />F1 Professional Services <br />E] Bid Opening <br />[:] Quote Opening <br />E] Change Order No. <br />E] Ease/Encroach. <br />F-1 Other: <br />Company or Vendor Name <br />!Tqp��a , _Le .. I - tem T " ype - Required for All Submissions <br />El Contract Proposal <br />OI Resolution <br />Bid Award Req. to Advertise <br />E] Quote Award <br />0 C/O & PCA No. El PCA <br />F-1 Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBEIWBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Required Information <br />Addendum <br />Z Title Sheet <br />El Yes Z No E] If Yes, Approved by <br />Purchasing. <br />MBE E] WBE <br />J:1 No 0 Yes.. Name of CqTRan y <br />,- ­­ . . . . ........... <br />Ewing Avenue and Fellows Street Traffic Signal Replacement <br />118-097 <br />........... <br />LRSA Traffic Signal Maintenance <br />251.0608.431.36-67 <br />L_J Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />.................. <br />. . . ................ . ..... Required For Change Orders <br />Amount of F-1 increase <br />El Decrease <br />Previous Amount $ <br />Current Percent of Change, % <br />4of Pql6fi, New Amount tsord V <br />Total Percent of Cha e: % <br />.............. <br />Disoersal After Atmroval A - OCT (11,111 d- <br />Copy <br />Original <br />F-1 <br />F-1 <br />F-1 <br />F-1 <br />El <br />El <br />