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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/27/16 <br />Name Toy Villa Department Engineering <br />BPW Date 11/08/16 Phone Extension 5920 <br />I <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal El Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />® <br />Change Order No. 2 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />F- <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Information <br />blocki Sign Co. <br />Yes ® No <br />MBE n WBE <br />No ❑ Yes Name of <br />115-103 <br />RWDA TIF <br />324.1050.450.42.03 <br />Added Acrylic backing to the 5 installed signs <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />For Chance Orders <br />$ 141,437.00 <br />1.44% <br />Dispersal After Approval <br />Aaron Kobb <br />I&Jlll~.1 <br />