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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/06/16 <br />Name Toy Villa Department Engineering <br />BPW Date 12/13/16 Phone Extension 5920 <br />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 />❑ <br />Agreement <br />Professional Services <br />❑ Contract ❑ Proposal <br />❑ Resolution ❑Addendum <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ❑ Re to Advertise <br />❑ Quote Award q Title Sheet <br />® <br />Change Order No. 1 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <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 />Kequired <br />❑ No LJ Yes Name of Companv <br />Tree <br />31 <br />202.0619A31.31.06 <br />Approval of C. O. #1 <br />❑ Required Contractor's Certification Form Attached (Non- <br />uired For Change Orders <br />Increase $ <br />Decrease $ 16 <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 />$ 11,729.00 <br />58.43% <br />Dispersal After Approval <br />Terri Swift <br />