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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />August 1, 2017 <br />Roger T. Nawrot <br />Purchasing <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />❑ Agreement <br />u Contract ❑ Proposal ❑ Addendum <br />® Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />n <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />MBEANBE 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 ofEl <br />Jones Petrie Rafinski Corporation <br />❑ Yes ® No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />El No ❑ Yes Name of Company <br />Ravina Park -Bowman Creek Bank Restoration <br />117-073 <br />Pokaqon Tribe Donation Fund <br />$4�9;000.00 <br />Not to Exceed <br />This includes the field survey, design and permitting for the bank <br />restoration project within Ravina Park. <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Nan -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />