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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date May 20, 2019 <br />Name Roger T. Nawrot <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date May 28, 2019 Phone Extension 5932 <br />,�r��v�xmr�a�axrw�mmu��uu a�emrrw�r��M ,�a� ��,„�mwm � �a�amr vw�rrturrrr�ur�✓iuur�,wmimmi�i�mo�uuivww,��mur�ie�m����.+�ia�svnmr�ww�z�mmmm��wmu�m�wu��wrmwiuiwwmumwu <br />y.............................�.�.__�.�. � .._....... . _..........—.................._�,�,�,..p__........_ ._.._ ._... _,_..,_.... <br />Rewired Prior to Submittal to Board <br />�....,...... _._._........ Lea � � <br />g I �] Attorney Name: <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the A <br />H Agreement <br />El Professional Services <br />Bid Opening <br />El Quote Opening <br />]' Change Order No. <br />Ease/Encroach. <br />F-1 Other: Amendment No. 1 <br />Company or Vendor Name <br />pro riate ItemmTy . . Reql <br />El Contract <br />Resolution <br />® Bid Award <br />❑ Quote Award <br />❑C/O &PCANo. <br />Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />for All Submissions <br />Proposa�....___._._.w_..�_ <br />❑ Req. to Advertise <br />Required Information <br />Walsh & Kelly, Inc. <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Lj Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />..........�� ��� . .... e uired For Chan e Orders On � . _.......� .... <br />R <br />ElIncr ���� <br />Amountof El Decrease......$..................................................................� <br />