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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/003/16 <br />Name Toy Villa Department Engineering <br />BPW Date 10/11/16 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 />Item Type — <br />LJ 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. 10 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <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 />Walsh & Kelly, Inc. <br />❑ Yes E No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />_❑ No ❑ Yes Name of Company <br />Ignition Park Infrastructure Phase 1C Division A <br />114-063A <br />RW DA TIF <br />324.1050.460.31.06 <br />Approval of Change Order #10 <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 />Increase $ 29,350.00 <br />Previous Amount <br />$ 4,219 <br />Current Percent of Change: <br />0.70% <br />New Amount <br />$ 4,248 <br />Total Percent of Change: <br />16.35% <br />Copy <br />Original <br />® <br />❑ <br />.91 <br />811.91 <br />Dispersal After Approval <br />Aaron Kobb, Judy Love <br />Roger Nawrot <br />