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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 11/22/16 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 />Check the Appropriate Item Type — Required for All Submissions <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. 5 <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 />Terms of Contract <br />Purpose/Description <br />Amount of N Increa <br />❑ Decree <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ Aaron <br />® <br />❑ Roger <br />® <br />❑ Toy VI <br />❑ Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />❑ Req. to Advertise <br />❑ PCA <br />❑ Title Sheet <br />Walsh & Kelly, Inc. <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />U No LJ Yes Name of Company <br />East Bank Sewer Separation — Phase 5 (Division B) Sewer Bond <br />114-062A j3 <br />Sewer Bond, TIF Bond <br />429.1050.460.31.02 <br />Approval of Change Order #5 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />4.5a% <br />Nawrot <br />ired For Chanqe Orders <br />I After Approval <br />Love, Beth Leonard <br />