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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/06/16 <br />Name Toy Villa �t J Department Engineering <br />BPW Date 12/13/16 Phone Extension 5920 <br />I 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 Tvpe — Required for All Submissions <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. 6 <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 <br />Previous Amount <br />Current Percent of Chanl <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />U Resolution <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />Required Informa <br />th Riley Construction <br />Yes Z No ❑ If <br />MBE I —I WBE <br />❑ Req. to Advertise <br />❑ PCA <br />Inc. <br />Approved by Purchasi <br />LJ No ❑ Yes Name of Company <br />Western Avenue Corridor Improvements <br />114-033B <br />Major Moves & River West TIF <br />412.0602.431.42.03 & 324.1050.460.42.03 <br />Approval of Change Order #6 <br />Addendum <br />❑ Title Sheet <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Aaron Kobb, Judy Love <br />Roger Nawrot <br />Orders <br />