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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 1/11/19 <br />Charlotte Brach _.. Department En meerin <br />Name C �.. .--��.......�.... <br />BPW Date 1/22/19 Phone Extension 9246 <br />...... _..... <br />Required Prior to Submittal __...oard..... <br />..... � ........�._ ....____�._......__ 'ttal to Board <br />Legal Attorney Name <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the <br />Agreement <br />El Professional Services <br />Bid Opening <br />Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />droi,e ItemmTyp <br />❑ Contract <br />Resolution <br />Bid Award <br />® Quote Award <br />❑ C/O &PCANo. <br />_ <br />❑ Traffic Control <br />for All Submissions <br />Proposal 0-Addendum <br />❑ Req. to Advertise ❑ Title Sheet <br />Required Information <br />Premier 1 Construction <br />Yes 0 No _ ._.mm..❑ If Yes <br />MBE � WBE <br />❑ PCA <br />by Purchasi <br />Ziker Sample Ctreet Building: Restroom Remodel <br />1m1mm7-123A <br />River West TIF <br />324-1050-460.42...02._...._.................................. <br />_...w <br />$ 45,976.00 <br />Lump Sum <br />Award Quote <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment E-Verify, Iran„ etc. <br />ReguiredITFor,C n,qq Orders Only <br />Amount of El Increase $ _N ...._ <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 />E <br />0 <br />El <br />El <br />El <br />r-1 <br />