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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/17/2016 <br />Name Kieran Fahey Department <br />Engineering <br />BPW Date 08/24/2016 Phone Extension 5993 <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 ❑ <br />Check the Appropriate Item Type <br />— Required for All Submissions <br />❑ Agreement <br />❑ Contract <br />❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />® Other: Board approval for <br />a basement back -flow device <br />co -pay scheme. See <br />pany or Vendor Name: N/A <br />New Vendor ❑ Yes ❑ No ❑ <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />If Yes, Approved by Purchasing <br />Name of Company <br />Wastewater <br />To have the Board aoorove a basement valve program for city <br />residents. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />