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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 6, 2016 <br />Name Roger Nawrot Department Engineering <br />BPW Date September 13, 2016 Phone Extension 5932 <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 />❑ Agreement ❑ Contract ❑Proposal ❑Addendum <br />® Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <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 />Amount of LJ Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />Kequirea Information <br />McCormick Engineering LLC <br />❑ Yes ® No ❑If Yes, Approved by Purchasing <br />LJ MBE N WBE <br />LJ No ❑ Yes Name of Company <br />Emergency Repair of the Randolph Street Storm Water Basin <br />116-083B <br />Major Moves <br />412.0602.431.42.03 <br />$12, 755.00 <br />Not to Exceed <br />10 prepare bid documents to repair the spillway washout out <br />caused by the August storm.. <br />Required Contractor's Certification Form Attached (Non- <br />�ollusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran, etc.' <br />ired For <br />Nawrot <br />ucl — Jitin Kain <br />Lawson — Fishe <br />