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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 4, 2019 <br />Name Roger T. Nawrot <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date November 12, 2019 Phone Extension 5932 <br />mumuuuuuuum�muwimmmmmi u�nra�v mmmmmmmmmm mm <br />.. .. _ R ouired Prior to Submittal to Board .. .__.... <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 />Agreement <br />Professional Services <br />E] Bid Opening <br />Quote Opening <br />❑ Change Order No. _ <br />�] Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />LJ Contract <br />Resolution <br />El Bid Award <br />❑p Quote Award <br />0 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 />Proposal <br />® Req. to Advertise <br />❑ PCA <br />Addendum <br />® Title Sheet <br />El Yes ® No. <br />....................�.- � a <br />El If Yes, Approved by <br />Purchasina <br />MBE ..W.B E........ <br />No Yes Name�of Com <br />L............ .... I v e s <br />t. Joseph River Backwater Vammmmm_wws <br />119-018 <br />Sewe....Fund ............w_......wm� .............. <br />226-0419-672.42-03 <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />- _.._._ - <br />__ ......: ....... Roq Ji ed For Ch Me Orders Onff._..:.. w .. <br />Amount of El Increase $ <br />.........� ._ �..._._ <br />.......mm <br />El Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount <br />Total Percent of Change % <br />Dispersal After Approval L n <br />Copy <br />Original <br />❑ <br />❑ <br />1 �, <br />