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BOARD OF PUBIJC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Data 06/13/2018 Department Public Works <br />. . .... ...... <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 ❑ Attorney Name: <br />Controller El 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 El <br />" Agreement Amendment <br />�E] Professional Services <br />F-1 Bid Opening <br />F-1 Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />LJ Contract <br />F-1 Resolution <br />Bid Award <br />Quote Award <br />E] C/O & PCA No. <br />El Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Proposal Ll Addendum <br />El Req. to Advertise El Title Sheet <br />Asphalt Restoration Services, LLC <br />El Yes E] No ❑ If Yes, Approved by <br />Purchasing . .. . ....... <br />-E[—MBE E] WBE <br />E] No E] Yes Name of Company <br />2017 Crack Sealing <br />117-102 <br />Funding Source <br />LRSA - Street Maintenance <br />Account No. <br />251.0608.431 36, 10 <br />Amount <br />$85,000.00 <br />Terms of Contract <br />Purpose/Description <br />E] Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran:, etc.) <br />Required, For Chart O�rders, Only <br />Amount of F-1 <br />F <br />increase $ <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total, Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />Roger Nawrot, Assistant City Engineer <br />F-1 <br />Derick Roberts, Streets Department <br />El El <br />