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BOARD OF PUBLIC WOIZI(S <br />AGENDA ITEM REVIEW REQUEST FOIM <br />Date 06/1'4/2018 Department Public Works <br />Name Toy Villa Division/Bureau Engineering <br />BPW Date 06/26/2018 Phone Extension 5920 <br />Required, Prior to Submittal to Board <br />Legal E] Attorney Name: <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length Iper the City Purchasing Policy <br />Purchasing El <br />[_1 Agreement <br />El Contract F] Proposal LJ Addendum <br />F] Professional Services <br />F-] Resolution <br />n Bid Opening <br />F <br />Bid Award El Req. to Advertise ❑ Title Sheet <br />E] <br />Quote Opening <br />El <br />Quote Award <br />Change Order No. 1 <br />F] C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />F] Traffic Control: <br />F-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />MBEANBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Premium Concrete Services, Inc. <br />❑ Yes Z No E] If Yes, Approved by Purchasing <br />❑ MBE F-1 WBE <br />E] No 0 Yes Name of Company <br />100 Wayne Street Plaza and Streetscape <br />116-047 (16J012) <br />RWDA <br />324-1050-460-42,03 <br />Approval of Change Order #1 <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of H Increase $ 32,850.00 <br />El Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />F-1 <br />D <br />F1 <br />El <br />❑ <br />$ 224,110-00 <br />14.66% <br />Ewr so I <br />k El X161 9 IV, �# <br />