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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />December 28, 2017 <br />Roger Nawrot <br />Department <br />Division/Bureau <br />Engineering <br />Public Works <br />❑ <br />Agreement Amendment <br />❑ Contract U Proposal U Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />® Traffic Control: <br />M Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEIWBE 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 />Previous Amount <br />U Increase <br />❑ Decrease <br />Current Percent of Change: <br />New Amount <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />n No n Yes Name of Company.... <br />Huey Street & Hamilton Street <br />TR117-065 <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />12 <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Roger Nawrot, Assistant City Engineer <br />Ed Gleckler, Manager Bureau of Traffic & Lighting <br />SBPD <br />