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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW I�X, QUEST FORM <br />Date <br />01/2012018 <br />Department <br />Public Works <br />Name <br />Toy Villa <br />Division/Bureau <br />Engineering <br />BPW Date <br />02,/13/20,18 <br />Phone Extension <br />59,20 <br />Recluired Prior to Submittal to Board <br />Legal F-1 Attorney Name: <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing R <br />H Agreement Amendment <br />U Contract LJ Proposal ❑ Addendum <br />F] Professional Services <br />F] Resolution <br />El Bid Opening <br />El Bid Award F] Req. to Advertise El Title Sheet <br />Quote Opening <br />El Quote Award <br />Change Order No. <br />❑ C/O & PCA No. PCA <br />❑ Ease/Encroach. <br />Traffic Control: <br />F-1 Other: <br />Company or Vendor Name <br />Asphalt Restoration Services, LLC <br />El Yes M No E] If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBEANBE Contractor <br />[:] MBE F] WBE mm <br />MBE/WBE Contractor Requested <br />F-1 No [J Yes Name of Company <br />Project Name <br />2017 Infrared Asphalt Pavement Patching <br />Project Number <br />117-074 <br />Funding Source <br />LRSA <br />Account No. <br />251,0608.431.36.10 <br />Amount <br />$ 57,250.00 <br />Terms of Contract <br />Purpose/Description <br />Project Closeout <br />El Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of F] increase $ <br />R Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of qhanqe: 1/o <br />Copy <br />Origiinal <br />E] Kara Boyles <br />F-1 Pete Kaminski and Derick Roberts <br />F Terri Swift <br />