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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 05/07/2019 Department Public Works <br />Name Toy Villa Division/Bureau Engineering <br />BPW Date 05/14/201 �9................................................�.�.............................�..�_............ Phone Extension ...�.5920�_ <br />rrrrrurnrmm.�nowaa mui � wummm�mmmmmmmm uumwwwwuwwwwmmmwumwe�.:r�rar,�rar mummw�000mmmom <br />Required Prior to Submittal to Board <br />� _..._. <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 11 <br />Check the <br />Agreement Amendment <br />❑ Professional Services <br />❑ Bid Opening <br />F-1 Quote Opening <br />® Change Order No. 5 <br />Ease/Encroach. <br />❑ Other: <br />Company or Vendor Name <br />�, o riate Item T <br />El Contract <br />❑ Resolution <br />El Bid Award <br />❑ Quote Award <br />❑ C/O &PCANo. <br />_ <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 />Purpose/Description <br />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />Required Information <br />❑ PCA <br />Ziolkowski Construction, Inc. <br />val of C.O. #5 <br />Addendum <br />❑ Title Sheet <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, _Non -Debarment, E-Ver fy Iran, etc. <br />µ squired For Chatinte Orders Only <br />Amount of V....J Increase <br />Decrease $ 553.00 <br />Previous Amount �.$ 3,645,�1.�62...00.....................................�.. <br />Current Percent of Change:. 0.02 /° <br />....................................................................................... <br />New Amount $ 3,644,549.00 <br />Total Percent of Chanvv ..........__.0.22% .....^.....mm...... . <br />Diseersal After Aoroval <br />Copy Original <br />® Steve Cox <br />® Todd Skwarcan <br />