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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 06/27/2016 <br />Name Nadia Correa <br />Public Works <br />Engineering <br />BPW Date 07/26/2016 Phone Extension 5796 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <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 ® George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. _ <br />❑ Ease/Encroach. <br />I —I Other: <br />Company or Vendor Name <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ 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 />Amount of ❑ Increase <br />❑ Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Department <br />Division/Bureau <br />❑ Req. to Advertise <br />❑ PCA <br />n <br />❑ Title Sheet <br />Jones Petrie Rafinski <br />❑ Yes ® No _0 If Yes, Approved by <br />H MBE ❑ WBE <br />No ❑ Yes Name of Company <br />Charles Black Center <br />Parks Bond <br />NTE $280,270 <br />To-mnallnt& Charles Black center _C -s <br />❑ Required Contractor's Certification Forms Attached (Non- �J <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />equired For Change Orders Only <br />Cecil Eastman <br />Therese DoraL <br />