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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/15/16 <br />Name Toy Villa Department Engineering <br />BPW Date 08/23/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ❑ 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 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. 1 Final ❑ 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 <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Required Information <br />C & S Masonry Restoration, LLC <br />❑ Yes ® No ❑ If Yes, AK <br />F1 MBE n WBE <br />No LJ Yes Name of Com <br />Century Center Masonry Restoration <br />ifi <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of ® Increase $ 1,890.00 <br />F- 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 />0 <br />7 <br />.32 <br />0.77% <br />$ 248,427.32 <br />0.77% <br />Nancy Collins <br />Toy Villa <br />Dispersal After Approval <br />