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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 07/18/16 <br />Name Toy Villa Department Engineering <br />BPW Date 07/26/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ❑ 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 ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />® Change Order No. 3 ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Required Information <br />Reith Riley Construction Co., Inc. <br />Ll Yes Z No ❑ If Yes Approved by Purchasing <br />F1 MBE I -I WBE <br />Requested <br />[ <br />Project Name <br />Sc <br />Project Number <br />11 <br />Funding Source <br />S: <br />Account No. <br />43 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />No LJ Yes Name of <br />ith Bend One Wav to <br />.36 <br />Approval of Change Order #3 <br />— Uivision A <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran, etc. <br />i Required For Change Orders Only 1 <br />Amount of ® Increase $ 6,156.05 <br />n Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />0.18% <br />$ 3,448,002.83 <br />1.47% <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ Michael Divita <br />® <br />❑ Toy Villa <br />® <br />❑ Beth Leonard, <br />