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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/01/16 <br />Name Toy Villa Department Engineering <br />BPW Date 11/08/16 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 ❑ Re to <br />❑ Quote Opening q Advertise Title Sheet <br />p g ❑Quote Award <br />® Change Order No. 5 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. 00 �p� ❑ Traffic Control <br />® Other: Ameldffif-ent <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 />Intormation <br />Premium Concrete <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />2016 Curb and Sidewalk <br />116-029 <br />MVH <br />202.0619.431.31.06 <br />Approval of C.O. #5 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Chanqe Orders Only <br />Amount of Increase <br />❑ Decrease <br />Previous Amount $ 4 <br />Current Percent of Change: 0.9 <br />New Amount $ 4 <br />Total Percent of Change: 12. <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Terri Swift <br />i! 0 <br />;37.00 <br />1.00 <br />70 <br />Atter <br />