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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 9/2/2016 Department <br />Name Nadia Correa Division/Bureau Engineering <br />BPW Date 9/13/2016 Phone Extension 5796 <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 />Public Works <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type <br />— Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract <br />❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />® Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />n <br />Other: <br />Company or Vendor Name <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 />Herrman & Goetz <br />❑ Yes No ❑ If Yes, Approved by Purchasing? <br />❑ MBE ❑ WBE <br />_❑ No Yes Name of Company <br />Martin Luther Kinq Jr. Center HVAC Revisions <br />Parks Bond Improvement Allocation Fund <br />Renovation and Replacement of HVAC units and equipment <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Only <br />Amount of ❑ Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of <br />py Original <br />® ❑ Aaron Perri — Parks & Recreation <br />® ❑ John Martinez — Parks & Recreation <br />® ❑ Tom Cook — M/E Design Services <br />