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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/20/17 <br />Name <br />Toy Villa <br />Department <br />Engineering <br />BPW Date <br />02/14/17 <br />Phone Extension <br />5920 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award Z <br />❑ Change Order No. ® C/O & PCA No.A' Final ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Required Informa <br />Ritschard Bros., Inc. <br />❑ Yes ® No ❑ If <br />❑ MBE ❑ WBE <br />Ani <br />L No L Yes Name of Company <br />Potawatomi Zoo Parking Lot Extension <br />115-0129A <br />Parks Capital <br />$ 110,407.60 <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Reauired For Chanae Orders Onlv <br />Increase $ <br />Decrease $ 3,214.40 <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 />❑ <br />❑ <br />$ 113, <br />2.83% <br />$ 110,407.60 <br />5.92% <br />Dispersal After Approval <br />