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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 217/17 <br />Department <br />Name John Martinez <br />Venues, Parks, & <br />Arts <br />BPW Date 2/14117 Phone Extension 235-7645 <br />Legal Attorney Name Michael Schmidt <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ® George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Bid Opening - Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Chg Order No. ❑ C/O & PCA No. ❑ PCA <br />Ease./Encroach. ❑ Traffic Control ❑ Resolution <br />Other:(9P$Rasrepo-,-A F ❑ Claim <br />Reauired 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 />Gametime <br />❑ Yes <br />® No <br />❑ MBE <br />F- WBE <br />Park Bond <br />41 <br />If Yes, Approved by Purchasing <br />Completed E-Verify Form Attached <br />Install <br />❑ Yes <br />❑ No <br />To remove the old damaged rubber surfacing and install new GT- <br />Impex play surfacing under our All Access Playground on site. <br />For Chanqe Orders Onlv <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />