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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />11/28/16 <br />Timmer <br />Department DCI <br />BPW Date 12/13/16 Phone Extension 5841 <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. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />Other: Amendment <br />Company or Vendor Name <br />Near Northwest Neighborhood Inc <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name <br />Acquisition -Rehabilitation Program <br />Project Number <br />15-JC-23 <br />Funding Source <br />Community Development Block Grant (CDBG) <br />Account No. <br />212.1001.460.39.30 <br />Amount <br />$200,000 (there will be no change in contract amount) <br />Terms of Contract <br />1/01/15 — 12/31/17 <br />Purpose/Description <br />Extend the contract timetable by 12 months through 12/31/17 to <br />allow for project completion <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 />Amount of ❑ Increase $ <br />❑ Decrease <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Judy Love <br />❑ ❑ <br />❑ ❑ <br />