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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />03/15/17 <br />Department <br />Public Works <br />Name <br />Toy Villa <br />Division/Bureau <br />Engineering <br />BPW Date <br />3/28/17 <br />Phone Extension <br />5920 <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name: Michael Schmidt <br />Controller El <br />review is required for all Contracts $5,000.00 or more and <br />greater <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ® PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />F Other: <br />Company or Vendor Name <br />New Vendor <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 />Amount of <br />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 />❑ <br />❑ <br />❑ <br />❑ <br />uired Information <br />DBL Services <br />El Yes 0 No ❑ If Yes, Approved by <br />Purchasing <br />Ll MBE F1 WBE <br />❑ No El Yes Name of Company <br />Potawatomi Zoo Parking Lot Striping <br />115-129B <br />Parks 403 Zoo Fund <br />75 <br />Project Closeout <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Chanqe Orders On <br />