Project Completion Affidavit - Fire Station No 4 Project No 116-066 - Gibson Lewis LLC

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BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 04/24/2019 Department Public Works Name Toy Villa Division/Bureau Engineering ..� .......................... _. BPW Date 05/14/2019 Phone Extension 5920 wwnvvrommvmx momrm��o Mmmuuiuummra�mmiwr�u �mmreirnmmmnirr m� OR MMMUmimuuuuwuu Required Prior to Submittal to Board Legal ❑ Attorney Name: Controller ❑ Controller review is required for all Contracts $5,000.00 or more and greater than one year in length per the City Purchasing Policy Purchasing El �m --- ______-....... Check the Agreement [❑ Professional Services ❑ Bid Opening F1 Quote Opening F-1 Change Order No. EJ Ease/Encroach. F� Other: Company or Vendor Name iropriate Item Typemm- El Contract El Resolution El Bid Award El Quote Award [] C/O &PCANo, El Traffic Control: New Vendor MBE/WBE Contractor MBE/WBE Contractor Requested Project Name Project Number Funding Source Account No. Amount Terms of Contract Purpose/Description d for All Submissions Proposal ❑ Req. to Advertise Required Information Gibson -Lewis, LLC Proiect Closeout Addendum ❑ Title Sheet ❑ Required Contractor's Certification Forms Attached (Non- _mmmm_mmCollusion, Non -Discrimination, wNon-Debarment, E Verify Iran, etc. quired ..FomCe Orders Only _.... Amount of ❑ Increase $ Decrease $ Previous Amount $ Current Percent of Change: %.�_�_....m.........�....................................................�........................... ...... ....._____ �N.. e........................�.�.�.�...........m.......�................................._.............. New Amount $ ...................................._............ �....._..._.................................................. Y Total Percent of Change: % Dispersal After Copy Original ❑ ❑ ❑ El F El