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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/28/2019 Department Public Works <br />.... __. ____. - ....... <br />Name Toy Villa ... <br />Division/Bureau Engineering <br />BPW Date 02/12/2019 Phone Extension 5920 <br />iuwowmmmm mmwmmim�imi�ummimimuwimuwiuwimuwimwwwwwwwwwwuwimwwurc v uono iu=M115111555M <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 ❑ <br />Check the <br />El Agreement Amendment <br />0 Professional Services <br />Fj Bid Opening <br />El Quote Opening <br />E] Change Order No. <br />EJ Ease/Encroach. <br />Other: <br />iropriate Item <br />Type Required ❑f Submissions <br />ContractEl <br />❑] Resolution <br />❑ Bid Award ❑ Req. to Advertise <br />[� Quote Award <br />C/O & PICA No, PICA <br />El 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 />Amount of Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of e Chan : % <br />g <br />New Amount $ <br />Total Percent of Chanee: % <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />D <br />0 <br />1:1 <br />uired Information <br />Ziolkowski Construction. Inc. <br />Addendum <br />❑ Title Sheet <br />Engineering Office Improvements mmmmm <br />118-107 <br />Professional..Servi.................................�...._._..................,,,,,,......�........... ..�..... <br />ces <br />101.0602.431.3106 <br />$9,233.00 <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />red For Chanee Orders Onl <br />Dispersal After A <br />