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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/14/16 <br />Name Toy Villa <br />Department Engineering <br />BPW Date 12/27/16 <br />Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller El <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 />greater <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ <br />Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />® <br />C/O & PCA No. 1 Final ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />❑ <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 Infori <br />HRP Construction Co. <br />❑ Yes ® No [ <br />I-1 MBE I-1 WBE <br />It <br />❑ No ❑ Yes Name of Company <br />Ireland Road Emergency Repairs <br />116-083E <br />404.0602.431.31.06 <br />Purchas <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 $ 7,717.50 <br />Previous Amount $ 67,218.05 <br />Current Percent of Change: 11.48% <br />New Amount $ 59,500.55 <br />Total Percent of Change: 11.48% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Roger Nawrot <br />® ❑ Toy Villa <br />❑ ❑ <br />