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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />1 �Department Public <br />ame Toy Villa " � D vs onureau Eng <br />ineering <br />NWorks <br />�...__ g g <br />BPW Date 01/22/2019 Phone Extension 5920 <br />iarrnimim�mmr�nnn �iom�ommimoouo�mio� ui �.............. ......................................_.........y�r�rra�mrmn ��, <br />Rtquired wPrior to�Sabmittal to Board <br />Legal ❑ Attorney Name: <br />Controller Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing El <br />.Check the <br />L JI Agreement <br />El Professional Services <br />El Bid Opening <br />❑ Quote Opening <br />[l Change Order No. <br />El Ease/Encroach. <br />F-B Other: <br />rooriate Item T oe Requ <br />El Contract <br />Resolution <br />El Bid Award <br />El Quote Award <br />® C/O & PCA No.2 Final <br />❑ Traffic Control: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />�m or All Submissions <br />.._.........W�..��� <br />j Proposal <br />❑ Req. to Advertise <br />ired Information <br />Proiect Closeout <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion Non -Discrimination„ Non -Debarment, E-Verify, Iran, etc. <br />wired For Change, Orders Only <br />Amount of 0' 00 <br />Increase <br />$ <br />Decrease ............ ............... dw.. <br />Previous Amount $ 256,960.00 <br />Current Percent of Change: 4.11 �.���.��.....�.�.� �........... ..�-�__...........�...._................................� <br />..........................��........w wr ��.............................................................�... <br />New Amount $ 267,518.00 <br />Total Percent of Chano: 19.37% <br />....... _ _ .�......__. ___ .... A,. ............... ___ ....... ........ <br />Disoersal After Aooroval <br />Copy <br />Original <br />❑ <br />❑ <br />El <br />0 <br />