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IAIL, /°I:.�S <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08-16-16 Department Public Works <br />Name Kevin Fink Division/Bureau Engineering <br />BPW Date 08-23-16 Phone Extension 5093 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Tifie Sheet <br />❑ Quote Opening ❑ Quote Award <br />E Change Order No. 1 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />F- Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor RenHested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />gE <br />If Yes, Approved by <br />LJ MBE U WBE <br />n No n Yes Name of Comoanv <br />Yard Lamppost Program 2016 <br />116-003 <br />404-0602-431.31-06 <br />Revise the contract amount due to less program applicants than <br />planned for in original contract <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />uired For Change Orders <br />m <br />-79.2% <br />$ 21,2E <br />-79.2% <br />Copy <br />Original <br />❑ <br />❑ Kevin Fink <br />❑ <br />❑ Toy Villa <br />❑ <br />❑ Patrick C. Kerr <br />