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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />late 04/23/2018 <br />Name Toy Villa <br />Department Engineering <br />BPW Date 05/08/2018 <br />Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal F-1 <br />Attorney Name <br />Controller El <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in <br />length per the City Purchasing Policy <br />Purchasing El <br />Check the Appropriate <br />Item Type — Required <br />f6rAH Subr issions <br />F-1 Agreement <br />F-1 Contract <br />[:1 Proposal El Addendum <br />F-1 Professional Services <br />F-1 Resolution <br />F-1 Bid Opening <br />F-1 Bid Award <br />E] Req. to Advertise F] Title Sheet <br />❑ Quote Opening <br />n Quote Award <br />Change Order No. <br />El C/O & PCA No. <br />PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />F-1 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 F-1 <br />El <br />Ziolkowski Construction, Inc. <br />EJ Yes H No [:1 If Yes, Approved by Purchasing <br />F-1 MBE F-1 WBE <br />2017 Engineering Remodel <br />117-116 <br />Building et Maintenance <br />101.0602.431.36.01 <br />;0919 pe WITt <br />Project Closeout <br />F-1 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <br />Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy <br />Original <br />F-1 <br />F] <br />F] <br />n <br />El <br />El <br />