Laserfiche WebLink
Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />12/15/16 <br />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 ❑ 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 />❑ 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. ❑ C/O & PCA No. ® PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />n 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 Information <br />J.L. Milling, Inc. <br />❑ Yes ®No <br />I-1 MBE I-1 W B <br />❑ No ❑ Yes Name of Company <br />2016 Cold Milling <br />116-030 <br />MVH <br />202.0607.431.36.01 <br />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 $ 17,865.94 <br />Previous Amount $ 48,150.00 <br />Current Percent of Change: 37.1 % <br />New Amount $ 30,284.06 <br />Total Percent of Change: 37.1 % <br />Dispersal After Approval <br />Copy Original <br />® ❑ Terri Swift <br />® ❑ Toy Villa <br />❑ ❑ <br />