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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/13/16 <br />Name Toy Villa <br />Department Engineering <br />BPW Date 12/27/16 <br />Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />® C/O & PCA No. 2(Final) ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />Green Demolition Contractors, Inc., Inc. <br />New Vendor <br />❑ Yes ®No ❑ If Yes Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />Demolition of Vacant & Abandoned Houses — Phase IX <br />Project Number <br />116-074B <br />Funding Source <br />EDIT <br />Account No. <br />408.1201.415.39.89 <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Amount of IN Increa <br />❑ Decree <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran. etc <br />Required For Change Orders Onlv <br />Copy Original <br />® ❑ Elizabeth Maradik, Beth Leonard, Judy Love <br />® ❑ Kevin Fink <br />® ❑ Toy Villa <br />