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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />10/18/2016 <br />Public Works <br />Engineering <br />BPW Date 10/25/2016 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 />❑ Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />® Change Order No. 4 <br />❑ Ease/Encroach. <br />❑ Other: <br />Nadia Correa <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control: <br />Department <br />Division/Bureau <br />❑ Req. to Advertise <br />❑ PCA <br />❑ Title Sheet <br />Required Information <br />Company or Vendor Name Premium Concrete <br />New Vendor El es ®No n If Yes Annrnvari by Pi irchacin ? <br />MBE/WBE Contractor ❑ ME <br />MBE/WBE Contractor Requested ❑ No <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 />Previous Amount <br />2016 C <br />116-02' <br />MVH <br />202-061 <br />WBE <br />as Name of <br />and Sidewalk <br />F31-06 <br />Time extension, 8 days <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase <br />Decrease $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Origin <br />❑ <br />❑ <br />