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BOARD OF PU13LIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/06/17 Department Public Works <br />Name <br />Toy Villa <br />Division/Bureau <br />Engineering <br />BPW Date <br />12/21/17 <br />Phone Extension <br />- - - -- -- ---- <br />5920 <br />Legal F-1 Attorney Name: <br />Controller ❑ Controller review is required 'for all Contracts $5,000.00 or imore and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />H Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑] Quote Opening <br />Change Order No. 4 <br />❑ Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />❑ Contract ❑ Proposal Ll Addendum <br />F1 Resolution <br />F-1 Bid Award ❑ Req. to Advertise 0 Title Sheet <br />❑ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBEA/VBE Contractor Requested <br />Project Name <br />Project Number <br />�Funding Source <br />Account No, <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Insituform Technoloaies <br />❑ Yes M No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />2016 Manhole and Sewer Lining <br />116-026 <br />Sewer Contractual Service <br />641.0621.792.6335 <br />Approval of'Change Order #4 <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of N Increase $3,398.85 <br />❑ Decrease $ <br />Previous Amount $ 2,996,336.05 <br />Current Percent of Change: 0.11% <br />New Amount $ 2,999,734.90 <br />Total Percent of Change: 1 Al % <br />Copy <br />Original <br />El <br />❑ <br />Tov Villa <br />