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Date <br />Name <br />10-31-16 <br />Kevin Fink <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 11-08-16 Phone Extension 5903 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />® Change Order No. 1 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control: <br />n Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of L l Increase <br />Previous Amount <br />$ <br />Current Percent of Change: <br />7. <br />New Amount <br />$ <br />Total Percent of Change: <br />7. <br />king Co., Inc. <br />s®No ❑ <br />E ❑ WBE <br />El Yes Name of Compai <br />s Street and Dubail Street <br />River West Development Area TIF <br />324.1050,460.31.02 <br />5 <br />Pu <br />See Specifications <br />1. Change Order for additional hydroblasting and asphalt <br />line removal <br />2. Add fourteen (14) days to contract <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />uired For Change Orders O <br />6 3.820.00 <br />15 <br />1 <br />py <br />® <br />Original <br />❑ Toy Villa <br />® <br />❑ Kevin Fink <br />