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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/18/18 <br />Name �..Sue.............................................�___ <br />Ellen Doudrick <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date 12/20/18 Phone Extension 5922 <br />�o �mm�mm�mmmm�wrrmH � r������w��w�w�w�w�u�w��rc�wai�,ur unmuomm� i�miomo�mr.�m��wm�mit uvusaaenewmn�o-7 „�,.,„�rrm ��� <br />,.­..------ <br />_......—.__ ... �.. w_....�............W.W.........W.........�........... ........�, ..__......... <br />,_., <br />I e uiredmmmmPrior to Submittal to Board <br />Legal [] Attorney Name: Clara McDaniels <br />Controller Controller 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 Ej Michael Schmidt <br />...._..._._ .._._ ..... <br />Check the Annrd riat a Item Twrvo Porminof4 for All Submissions <br />i <br />Agreement g Amendment <br />❑ Professional Services <br />❑ Bid Opening <br />El Quote Opening <br />❑ Change Order No. <br />El Ease/Encroach, <br />Other: <br />Company or Vendor Name <br />F] Contract <br />EJ Resolution <br />® Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Proposal �.. <br />❑ Req. to Advertise <br />Required Information <br />❑ PCA <br />Addendum <br />® Title Sheet <br />Drainage Improvements to 1) Olivia Circle 2) Creekwood <br />i Street <br />Purpose/Description Estates,3 Hawbaker Seet .. .__...�.. � .. ... <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />luired For Change Orders Oni <br />Amount of ❑ Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: % <br />Copy Original <br />® �] Kara Boyles <br />® E Sue Ellen Doudrick <br />