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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/ 16/2019 <br />Name TqVilla Department Enincerin <br />�.�... ......... <br />BPW Date 08/27/2019 Phone Extension 5920 <br />uHiHiHuuHuuHuuuHiuiwiwiwiwuHiH ar �rmmarMttsw�„�mmmrm.�rmiimruawnn�,�.:: ��.;�,;x..................��.�ssrx�cu����ruw�rrvmaa,�i��rarvrssr.�a�uuuuuuumrr�wwmriuuuuuuuuuuumuuuuuunm�w�mrrmrvas;�au�rr� rs:�e�ays�.�.�.,�.,��.A,a�.Anaaa�.�saum�r����uu�rvmmmwmi�wwr <br />........... __ wired Re Prior to S — e............ <br />.Re Submittal to Board...... ..... ...,,,�... <br />Legal ❑ Attorney Name <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more anc <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the <br />Agreement <br />Professional Services <br />Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. _ <br />❑ Ease/Encroach. <br />El Other: <br />Mrriate Item Type ler <br />M Contract <br />El Resolution <br />❑ Bid Award <br />F-1 Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />d for All Submissions <br />U Proposal L Addendum <br />❑ Req. to Advertise ❑ Title Sheet <br />Required Information <br />Company or Vendor Name Niezgodski Plumbing, Inc. <br />New Vendor <br />0 Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />Projectto <br />Name <br />Lafayette Building_Dram Replacement _.. �. ....... <br />Project Number <br />1 19-042 A <br />Funding Source <br />RWDA <br />Account No. <br />............ ..... ....... ...... ,__._­­ .............. m. <br />324-1050-460-42.02 <br />Amount <br />$57,87. ....... ......... .......__--------...-_...................._._._._ <br />2.60 <br />Terms of Contract <br />_... .....-. ....... _... __ ... ----- ....................... .............. <br />Purpose/Description <br />�Project Closeout ........... ---- ---- ---_ __ __._ �. ��..�... _..................�.��.. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion„ Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Recuired For Chanae Orders On <br />Amount of Increase <br />Decrease $ <br />..................... <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount. <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />