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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 4, 2019 <br />Department Public Works <br />Name Roger T. Nawrot Division/Bureau Engineering <br />BPW Date November 11, 2019 Phone Extension 5932 <br />_...... . _ <br />Required Prior to Submittal to Board <br />.......... ......... ......._.......... ......... <br />Legal 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 El <br />Check the <br />Agreement <br />Professional Services <br />Bid Opening <br />❑l Quote Opening <br />F Change Order No. _ <br />❑ Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />Topriate Item Type — <br />El Contract <br />❑ Resolution <br />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 />for All Submissions <br />n Proposal <br />® Req. to Advertise <br />uired Information <br />❑ PCA <br />Addendum <br />® Title Sheet <br />.. �_..�._...�...�®.�.���_.�..._. . .�..................................� <br />Ye ❑ If Yes, Approved by <br />Purchasin q <br />......._.......... <br />_.........�......................�.--------------------------------------------------------- <br />___.. <br />�] MBE ❑ WBE _ _ <br />No EJ Yes Name of Com an mm mm ....m _._._._.._..._._._...._._... ..... <br />Miami Basin Valve Replacement <br />_..11w6-082.D_._..._..._._._.........._.. wwww <br />Sewer Fund and South Side TIF <br />_........................................�.�.�.�.,�.�-�.�.�.�.�...................___....._w_w.-........._w.....................�.....-. <br />226-0419-672.42- 3 430-1050-460.42-01 <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Reww uired For Change Orders Only <br />Amount of F-1 Increase $ _._._.._.. .___...________ __...__.. ___... <br />(:1 Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />.......% .........................��........................................�_..............�_ <br />_.e.e...................._............. .-.. ��...........................................................................�m......m..m. <br />New Amount $ <br />Total Percent of Chance mm m ... % .t <br />�. .. ..........._..........— . � a <br />. ...__...__..__._� Dispersal After Ap oval ._ .. I W <br />Copy Original <br />❑I <br />❑ R <br />