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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 02/07/2019 Department Public Works <br />Name Toy Villa � Division/Bureau �Engineeri ng <br />BPW Date 02/26/2019 Phone Extension 5920 <br />�� iurew mlimummmmmm mmmmmmn7l'momoummuweuwwuwww <br />- .... ........_......._....... _.............. <br />..�...�. <br />Required Prior to Submittal to Board <br />Legal ....El Attorney Name: ITITITmmmITITITITITITmmm�WWWW��W� <br />Controller El Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing El <br />Check the <br />j Agreement Amendment <br />❑ Professional Services <br />❑, Bid Opening <br />F Quote Opening <br />❑ Change Order No. <br />0 Ease/Encroach. <br />F Other: <br />Company or Vendor Name <br />iropriate Item Tree — Rem <br />❑ Contract <br />Resolution <br />Bid Award <br />[� Quote Award <br />�j C/O & PCA No. <br />❑ Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />for All Submissions <br />I Proposal <br />❑ Req. to Advertise <br />ired Information <br />Larson -Danielson Construction Co., Inc. <br />Addendum <br />❑ Title Sheet <br />Purpose/Description Project Closeou <br />t <br />❑ Required Contractor's Certification Forms Attached (Non- <br />Collusion,IT Non -Discrimination„ Non -Debarment, E-Vergy�mmmIran, mmmetc. <br />Required For Change Orders Only <br />Amount of El Increase �$ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Disoersal After Aohroval <br />Copy <br />Original <br />❑ <br />❑ <br />El <br />❑ <br />