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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 12, 2016 Department Public Works <br />Name Roger T. Nawrot Division/Bureau Engineering <br />BPW Date December 22, 2016 Phone Extension 5932 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: <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 />Purchasing ❑ <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />❑ Contract <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑C/O &PCANo. <br />® Traffic Control: <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 />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />❑ Title Sheet <br />❑ Yes ® No ❑ If Yes, Approved by <br />Lj MBE U WBE <br />❑ No ❑ Yes Name of Company <br />Eddy Street at the St. Vincent Street Intersection <br />TR16-108 <br />No parking zone in all four quadrants of the intersection. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ Engineering - Roger Nawrot <br />❑ ❑ Traffic & Lighting — Ed Gleckler <br />❑ ❑ SB Police Dept. — Eugene Eyster <br />