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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date April 12, 2019 <br />Name Roger T. Nawrot <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date April 23, 2019 Phone Extension 5932 <br />_. <br />R,e uired Prior to Submittal 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 A <br />H Agreement <br />El Professional Services <br />E] Bid Opening <br />El Quote Opening <br />Change Order No. <br />�] Ease/Encroach. <br />Other: Amendment No. 1 <br />Company or Vendor Name <br />Nropriat Item y ae_ <br />El Contract <br />El Resolution <br />El Bid Award <br />El 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 />Purpose/Description <br />for All Submissions <br />1 Proposal <br />® Req. to Advertise <br />uired Information <br />❑ PCA <br />Addendum <br />® Title Sheet <br />❑ Yes ❑ No ❑ If Yes, Approved by <br />Purchasing <br />�] BE WBEIT- <br />❑ No E] Yes Name of Coman <br />_....... ._u _._...... <br />Michigan Street Reconstruction <br />118-&5 <br />Bids due May 14, 2019 Adv. Dates April 23 & May 3 <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of El $ r , <br />❑ Decrease $ ............ _._� �..... ....i. <br />Previous Amount $ Q <br />............. . ..... <br />Current Percent of Change: ...._ %_r <br />New Amount $- <br />Total Percent of Change: <br />.... _ Dis ersaI After Approval .... _ _. w::.: <br />......._....__ <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />