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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 9/6/2016 Department <br />Name Nadia Correa Division/Bureau Engineering <br />BPW Date 9/13/2016 Phone Extension 5796 <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 />Public Works <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. 1 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />❑ Other: <br />Required Information <br />Company or Vendor Name Walsh & Kelly <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasina? <br />MBE/WBE 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 />MBE U WBE <br />No ❑ Yes M <br />avette Falls Su <br />115-086 <br />LRSA <br />251.0608.380.10.99 <br />HMA pavement overrun <br />L_J Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <br />Amount of ® Increase $ 67663.20 <br />❑ Decrease $ <br />Previous Amount $ 193035.00 <br />Current Percent of Change: 35.05% <br />New Amount $ 260698.20 <br />Total Percent of Change: 35.05% <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />7 <br />❑ <br />