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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />ate <br />Dame �`+���yVi la 1 � N�Department Enc ineenng mm <br />BPW Date 09/10/2019 Phone Extension 5920 <br />%WWWNI��iu,1iJdN�PUdAINiWWWN�IWNflflflf�lRiIG11VNN'OY�1%1'll�%Immmmmmmmlllllllllllllllllllllllllllllllllllllllllmlmllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll�ltl/0/iA�i� WMiMWIW'NMMONM'.��flIIMmMMWW V �' �iililWI�VIWWWWW g <br />�:r�uiredwPriorto 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 E] <br />Check the <br />Agreement <br />EJ Professional Services <br />E] Bid Opening <br />E] Quote Opening <br />❑I Change Order No. <br />Ease/Encroach. <br />❑ Other: <br />Grorate Item Type — ,lei <br />0 Contract <br />0 Resolution <br />F] Bid Award <br />Quote Award <br />El C/O & PCA No. <br />F] Traffic Control <br />for All Submissions <br />EProposal [ Adde <br />ndum <br />EJ Req. to Advertise ❑ Title Sheet <br />ired Information <br />Company or Vendor Name Gibson -Lewis LLC <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Charles Black Center Renovation <br />ProjectNumber <br />.................................................. __ �.....�.....�..m <br />116-073 <br />Funding Source <br />Park Bond <br />Account No. <br />751.1101.4,�,� � ..................ww.......,w�____ �................................................���... <br />52.39.89 <br />Amount <br />$3, 0 973,460.0.............. ........................ .........._w.,.,.,.---- ,.............. �....................................... <br />Terms of Contract <br />Purpose/Description Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verif. Iran. etc. <br />For Change Orders On <br />Amount of ❑ Increase $ <br />❑ Decrease $ <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 />El <br />F-1 <br />El <br />F-1 <br />❑a <br />0 <br />