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Date 12/6/2016 <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department Public Works <br />Name Richard Estes Division/Bureau Engineering <br />BPW Date 12/13/2016 Phone Extension 5896 <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 />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. 1 <br />Ease/Encroach. <br />Other: <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control: <br />Company or Vendor Name HGR <br />New Vendor —� <br />MBE/WBE Contractor —TM_ <br />MBE/WBE Contractor Requested ❑ N, <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 />:) Inc. <br />No M If <br />Yes <br />rIF <br />324-1050-460-3102 <br />❑ Req. to Advertise <br />❑ PCA <br />Stair T <br />Addendum <br />❑ Title Sheet <br />L;nange orcer to reflect delay claims of 14 calendar days <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase Add 14 <br />Decrease $ <br />Previous Completion Date <br />Current Percent of Change: <br />New Completion Date <br />Total Percent of <br />Copy <br />Origina <br />® <br />❑ <br />® <br />❑ <br />® <br />7 <br />12/23/2016 <br />01 /06/2017 <br />Patrick C. Kerr <br />Matt Douhan <br />