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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/13/2017 Department <br />Name Richard Estes Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 01/24/2017 Phone Extension 5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <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 ❑ George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBEM/BE 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 />uired Information <br />scneouie: 1Aa"1-ul//1, AdZ-UZ/U3, bids UUe U2/14 ` <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Onlv I <br />Amount of <br />Increase <br />Decrease <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy <br />Origin <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Patrick C Kerr <br />Aaron Kobb <br />Dave Sieradzki (Century Builders) <br />