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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/3/2019 _ <br />Name Sue Ellen Doudrick <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date 12/10/2019 Phone Extension 9246 <br />uummmmi mwmmw�mwwwmro arm SHE wm <br />.. ........... ....... ........... ]I <br />�..._.__. Required Prior to Submittal to Board <br />Legal Z Attorney Name: Clara McDaniels... WW <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 />E] Professional Services <br />Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />Ej Ease/Encroach. <br />l Other: <br />Company or Vendor Name <br />)ropriate Item T — IT <br />El Contract <br />❑ Resolution <br />El Bid Award <br />Quote Award <br />C/O &PCANo. <br />_ <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 />Amount of LJ Increase <br />Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Chance: <br />Copy <br />Original <br />® <br />❑ <br />F1 <br />El <br />for _All Submissions <br />Proposal <br />❑ Req. to Advertise <br />Required Information <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Danch„ Harner, & Associates <br />El Yes 0 No ❑ If Yes, Approved b <br />Purchasina L� <br />.. . <br />[� MBE R WBE w y <br />............ <br />No ❑ Yes Name of Com an <br />Small Drnin nP DPSinn and RPn it . <br />Lump Sum <br />Preparation of and negotiations with homeowner for an <br />easement. <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />111 <br />ired For Chanqe Orders On <br />Dispersal After Approval <br />Kara Boyles <br />Sue Ellen Doudrick <br />