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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/15/16 <br />Name Toy Villa Department Engineering <br />BPW Date 12/22/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />® Change Order No. 11 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Required Information <br />Walsh & Kelly, Inc. <br />❑ Yes ® No ❑ If Yes, Approved by Pu <br />I-1 MBE I-1 WBE <br />❑ No ❑ Yes Name of Company <br />Ignition Park Infrastructure Phase I Division A <br />114-063A <br />RWDA TIF <br />324.1050.460.31.06 <br />Approval of Change Order #11 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Reauired For Chanae Orders Only <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ❑ Aaron <br />® ❑ Roger <br />® ❑ Toy V <br />7 <br />$ 4,248,811.91 <br />0.67% <br />$ 4,277,077.38 <br />17.13% <br />Love <br />Approval <br />