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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />01 /0912017 <br />Richard Estes <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 01/24/2017 Phone Extension 5896 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <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 ® George King <br />Check the Aoorooriate Item TVoe — Reauired for All Submissinns <br />"Agreement <br />U Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services ❑ Resolution <br />❑ <br />Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ Quote Award <br />® <br />Change Order No. 1 ❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ Traffic Control: <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name DBL Services Inc. <br />New Vendor 1-1 Yes M No I-1 If Yes. ADoroved by Purchasina <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Yes <br />15-129B <br />Lot <br />Parks Capital Improvements <br />Contract extension due to inclement weather. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />1 Required For Change Orders Only <br />Amount of ® Increase $ additional 59 calendar days <br />❑ Decrease $ <br />Previous Amount $ 4,598.75 <br />Current Percent of Change: 0% <br />New Amount <br />Total Percent of <br />0% <br />1b <br />Dispersal After Approval <br />Copy Original <br />® ❑ Patrick C. Kerr <br />® ❑ David Letcher (DBL) <br />® ❑ John Martinez <br />