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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/16/16 <br />Name Toy Villa iVv�r Department Engineering <br />BPW Date 08/23/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller El greater <br />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 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 />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 />red Information <br />Lochmueller Grou <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />I -I MBE ❑ WBE <br />Yes Name of Corn <br />One Way to Two Way Conversion — Construction Observation <br />TIF Bond <br />Original Contract amount of $249,800.00 + additional Inspection <br />Observation of $97,600.00 for a new total of $347,400.00 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran. etc. <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />ired <br />rders <br />Dispersal After Approval <br />Michael Divita, Elizabeth Leonard <br />Toy Villa <br />