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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />.tune 5, 2018 <br />Roger Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date June 12, 2018 Phone Extension 5932 <br />❑ Agreement <br />H Contract LJ Proposal � ,j Addendum <br />® Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />n Other: <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBEIWBE Contractor Requested <br />Project Name <br />Project Number <br />Jones Petrie Rafinski Corporal <br />❑ Yes ®No <br />Purchasing <br />❑ MBE ❑ WBE <br />f l No I-1 Yes Name of Comr <br />If Yes, Approved by <br />On -Call Land Surveying/Right-of-Way Services <br />118-065 <br />Funding Source <br />Professional Services <br />Account No. <br />101-0602-431.31-06 <br />Amount <br />$10,000.00 <br />Terms of Contract <br />Not to Exceed <br />Purpose/Description <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />. <br />Re <br />ured <br />For C�iarr e Or.ers Onl <br />Amount of ❑ <br />Increase <br />$ <br />❑ <br />Decrease <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval — <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />