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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />February 21, 2017 <br />Roger Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date February 28, 2017 Phone Extension 5932 <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 />Check the Appropriate Item Type — <br />Required for All Submissions <br />❑ <br />Agreement Amendment <br />❑ Contract <br />❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ <br />Ease/Encroach. <br />® Traffic Control: <br />❑ <br />Other: <br />uired Information <br />Company or Vendor Name <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name 718 S. 2810 Street Residential Handicap Parking <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chanae: % <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />M <br />Assistant C <br />of Traffic & <br />