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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />07/26/16 <br />Corbitt Kerr <br />Department Public Works <br />BPW Date 07/26/16 Phone Extension 5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />Trinity Continuing Care Services d/b/a Sanctuary at St. Paul's <br />New Vendor <br />❑ Yes 0 No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />Temporary Construction Access and Access to Sewer Agreement <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />St. Pau's currently discharges into a City basin that is part of the City's <br />Separated Sewer System. This is an agreement to allow use of the city <br />system. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />