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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW RE, QUEST FORM <br />Date 11/17/1'7 <br />Name To Villa Department Engineering Division <br />BP W Date 11/28/17 Phone Extension 5920 <br />R aired Prior to Submittal to hoard <br />Legal F-1 Attorney Name <br />Controller Controller review is required for all Contracts $,5,000.100 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing F] <br />Agreement <br />Professional Services <br />E] Bid Opening <br />F-1 Quote Opening <br />F-1 Change Order No. <br />F1 Ease/Encroach. <br />F] Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />MBE/VVBE 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 />L] Contract <br />El Resolution <br />El Bid Award <br />F-1 Quote Award <br />Z C/O & PCA No. 1 (final) <br />F-1 Traffic Control <br />Gibson -Lewis. LLC <br />a Me- <br />❑ Req. to Advertise El Title Sheet <br />EM <br />[:] Yes Z No Ll If Yes, Approved by Purchasing <br />19 MBE 9 WBE <br />0 No El Yes Name of Company <br />2016 Bus Shelters <br />COIT <br />401.1001.460.42.03 <br />Project Closeout <br />F-1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of Z increase $3,293.13 <br />n Decrease $ <br />Previous Amount $ 151,241 A0 <br />Current Percent of Change: 2.18% <br />New Amount $ 154,534.53 <br />Total Percent of Change: 6.60% <br />Dispersal After Approval <br />Copy Original <br />n F-1 <br />F-1 El <br />