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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/17/16 <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 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 />the Appropriate Item Tvoe — <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <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 />❑ Contract <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />® C/O & PCA No. 1 Final <br />❑ Traffic Control <br />Required Information <br />markin Co., Inc. <br />Yes No ❑ If Yes <br />MBE ❑ WBE <br />No F Yes Name of Co <br />!d for All Submissions <br />❑ Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Approved by Purchasi <br />mpany <br />Phase I <br />❑ Title Sheet <br />Terms of Contract <br />Purpose/Description Project Closeout <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 $ 346.00 <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 />❑ <br />❑ <br />57 <br />0.61 % <br />$ 56,738.00 <br />0.61 % <br />Dispersal After Approval <br />Cecil Eastman <br />Toy Villa <br />