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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 />I Check the Appropriate Item Type — Required for Ail Submissions <br />❑ Agreement ❑ Contract ❑Pro osal <br />❑ Professional Services p ❑Addendum <br />❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Re <br />El Quote Opening ❑ Quote Award q to Advertise ❑Title Sheet <br />❑ Change Order No. ❑ 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 />Required Information <br />❑ No ❑ Yes Name of Comoanv <br />Pan <br />116-09 <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran_ etc <br />Amount of Lj Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy <br />Original <br />❑ <br />❑ <br />Ron O'Connor <br />vma <br />or Change Orders O <br />Dispersal After <br />