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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 09/4/2018 <br />Name �e_Silveus Department Engineering <br />- ... . . . .. . ...... ..... . .......... <br />BPW Date 09/11/2018 Phone Extension 9083 <br />Required Prior to Submittal to —Bo—ard— <br />Legal E] Attorney Name Clara McDaniels <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 Michael Schmidt <br />Check the Appropriate Item Type - Required for All Submissions ❑ <br />R,. <br />[J Agreement ❑Contract 0 Proposal ElAddendurn <br />F-1 Professional Services F-1 Resolution <br />F-1 Bid Opening El Bid Award Req. to Advertise E] Title Sheet <br />F-1 Quote Opening R Quote Award <br />[:1 Change Order No. F-1 C/O & PGA No. ❑ PCA <br />F-1 Ease/Encroach, F] Traffic Control <br />❑ Other: <br />Required Information ❑ <br />Company or Vendor Name TBD <br />New Vendor 0 YesE:1 No 0 If Yes, Approved by Purchasing <br />MBE/WBE Contractor F-1 MBE F WBE <br />MBEANBE Contractor Requested F-1 NoF-1 Yes Name of Company <br />Project Name Gemini Washington -Colfax Masonry,and Stair Repairs <br />Project Number 118-080B <br />Funding Source <br />Account No,. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />West Washington TI F <br />422-1050-460-42.02 <br />Mim <br />s <br />L] Required Contractor's Certification Form Attached (Non- <br />CoHusjon, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Pn jy <br />Amount of ❑ increase $ <br />El Decrease $fXI <br />Previous Amount $ Of Ian <br />Current Percent of Change: % <br />New Amount <br />Total Percent of Chan <br />Copy <br />Original <br />F-1 <br />F-1 <br />El <br />❑ <br />