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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 13, 2019 Department Public Works <br />Name Roger T. Nawrot Division/Bureau Engineering <br />" ----------- . ..... ................................. ...... <br />BPW Date December 19, 2019 Phone Extension 5932 <br />lIII <br />Required 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 El <br />. . . .... . . . ........... . . ..... . ........... <br />. ..... Check the <br />- <br />E] Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />❑ Change Order No. <br />Ease/Encroach. <br />E] Other: <br />Company or Vendor Name <br />pro ria�te Item Tree <br />El Contract <br />F] Resolution <br />Z Bid Award <br />El Quote Award <br />El C/O & PCA No. <br />n 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 />for All Sut <br />i Proposal <br />0 Req. to Advertise <br />Required Information <br />R PCA <br />Selqe Construction Co., Inc. <br />...... .......... _ ........ - . ......... <br />Addendum <br />❑ Title Sheet <br />El Yes Z No El If Yes, Approved by <br />Purchasing .. . . . ........... ------- <br />[:] MBE [:] WBE <br />:D-No 0 Yes Name of Complan <br />. .................. <br />St. Joseph River Backwater Valves <br />_1 _19-018 <br />... ..... ..... ... .... <br />L R SA a p i tal <br />.............. . . ........... .............. <br />251-0608-431.42-96 ww <br />$94',­4'50b 0 .. .......... ........ . ... .......................... . . <br />Terms of Contract <br />. .......... ...... - ...... <br />Purpose/Description <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Chanae Orders Only <br />Amount of F] increase <br />Ej Decrease <br />Previous Amount $ <br />--­­-­­---­--- Current Percent of Change.- % <br />New Amount <br />Total Percent of Chance: % <br />Copy <br />Original <br />F-1 <br />F-1 <br />F� <br />