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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />01/10/2017 <br />Hanako Parkhill <br />Department Public Works <br />BPW Date 01/24/2017 Phone Extension 5961 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ® Quote Award <br />❑ Chg Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease./Encroach. ❑ Traffic Control ❑ Resolution <br />❑ Other: ❑ Claim <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <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 />Acorn LE <br />❑ Yes <br />® No <br />❑ MBE <br />1 WBE <br />;LLC <br />If Yes, <br />Completed E-Verify Form Attached ❑ Yes <br />❑ No <br />2017 Downspout Disconnect Program <br />116-114 <br />Wastewater O&M <br />641-0630-793-6335 <br />Completion date of 360 calendar days <br />Award quote for the 2017 Downspout Disconnect Program at the <br />Regular meeting. <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />PO No. <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />Orders <br />U�0 <br />Dispersal After <br />Hanako Parkhill <br />Toy Villa <br />Carol Kurzhal <br />