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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/01/16 <br />Name Toy Villa Department Engineering <br />BPW Date 12/13/16 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 El <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 <br />❑ Quote Opening ❑ Quote Award q to Advertise ❑Title Sheet <br />® Change Order No. 1 ❑ 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 />Required Information <br />JCI Bridge Group, Inc. <br />U Yes N No ❑ If Yes Approved by Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Chippewa Avenue Emergency Repairs <br />116-083F <br />1.31 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Only <br />Amount of ® Increase $ 9,369.50 <br />❑ Decrease $ <br />Previous Amount $ 174,394.75 <br />Current Percent of Change: 5.37% <br />New Amount $ 183,764.25 <br />Total Percent of Change: 5.37% <br />Copy <br />Original <br />Nawrot <br />Dispersal After Approval <br />