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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/03/17 <br />Name Toy Villa Department Engineering <br />BPW Date 01/10/17 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 />❑ 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. 5 ❑ 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 />Kequired Information <br />Premium Concrete <br />El Yes ®No ❑ If Yes. ADDroved by Purchasina <br />❑ No LJ Yes Name of Company <br />2016 Curb and Sidewalk <br />116-029 <br />MVH <br />9.431.31.06 <br />404,298.70 <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non -Debarment_ F-Verifv Iran Pt( <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />Terri Swift <br />Villa <br />For Chance Orders <br />Dispersal After <br />