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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/03/17 <br />Name <br />Toy Villa <br />Department <br />Engineering <br />BPW Date <br />01/10/17 <br />Phone Extension <br />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 Type — Required for All Submissions <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. 1 <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 />Contract <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control <br />Kequired Information <br />Walsh & Kelly, Inc. <br />❑ Yes ® No ❑ If Yes <br />❑ MBE I -I WBE <br />❑ Req. to Advertise <br />❑ No ❑ Yes Name of Company <br />Ireland Road Storm Repairs <br />11 <br />COIT <br />404.0602.431.31.06 <br />Qao oru I)G <br />Project Closeout <br />Addendum <br />❑ Title Sheet <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <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 />❑ <br />❑ <br />er Nawrot <br />Villa <br />Dispersal After <br />