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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Public Works <br />Division/Bureau Engineering <br />BPW Date 11/22/2016 Phone Extension 5896 <br />11 /16/2016 Department <br />Richard Estes <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 />® <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />I-1 <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 <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chance: <br />Information <br />_LJ Yes U No U If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />Ll No ❑ Yes Name of ComDanv <br />Effective until the earlier of (a) the examination is done, (b) <br />December 31, 2016 <br />Temporary Access Agreement for Notre Dame to perform Soil <br />Borings for the ND Hydro Project. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />uired For Change Orders <br />Copy Original <br />® ❑ Patrick C Kerr, Therese Dorau <br />® ❑ Aaron Perri, Paul Moreland, Brian Pau <br />® ❑ Ben Dougherty <br />