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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/11/19 Department Public Works <br />Name Kyle Silveus ........................�.. ._...��_.__�..._�.......�,�_ <br />Division/Bureau Engin <br />eering <br />BPW Date 10/22/2019 d Phone Extension 9083 <br />immmimiMIIIEi�vwioivu m: mur zzrsa �esu a asr mimiWuwuwimmwwwmv�.rrrtimNOK wwiurWud m iMINVwioi(09 ✓er�w iaee� <br />�equlred Prior to Submittal to Board <br />Legal ❑ Attorney Name: Clara McDaniels <br />Controller El Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing F-1 Michael Schmidt <br />_ Check the Appropriate Item T rp Requires for All Submissions <br />❑ Agreement Contract Pro osalp Addendum <br />EJ Professional Services ❑ Resolution <br />(] Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />F Quote Opening ❑ Quote Award <br />® Change Order No. 3 [:] C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. F] Traffic Control: <br />0 Other: <br />. ._ _._.._._ .......... _ ... ._.... ..... ........ _...... <br />Rea aired Information <br />Company or Vendor Name <br />Rieth Rile <br />New Vendor <br />m.._.. <br />Yes No- As Yes„ Ap roved b Purchasin ..�.. u <br />MBE/WBE Contractor <br />❑ <br />MBE WBE <br />MBE/WBE Contractor Requested <br />E. <br />No Yes Name„of Com and <br />Project Name <br />J C Lauber Site Improvements <br />�... ,..... <br />Project Number <br />118-083 B ..— ........... <br />FundingSource <br />RIVER EAST DEVELOPMENT <br />PMENT TIF <br />Account No. <br />429-1050-460-42.03 <br />Amount-_�8.).8.82.38............ <br />.��._ r�r �......�....�_.,�.�.�.�................__��....m. <br />Terms of Contract <br />Purpose/Description <br />Under round fuel tank, final quantity <br />,_..... _ o_ tity <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />__...._. Require afj Orders OnI �mITITm_ <br />Amount of Z Increase <br />$,�82 38 <br />Decrease <br />