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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 09/02/16 <br />Name Toy Villa Department Engineering <br />BPW Date 09/13/16 Phone Extension 5920 <br />I 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 />I Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />® <br />Other: Amendment <br />Required Information <br />Company or Vendor Name <br />Dale Clin erman <br />New Vendor <br />❑ Yes Z No ❑ If Yes Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />One Way to Two Way Conversion <br />Project Number <br />116-001 <br />Funding Source <br />TIF Bond <br />Account No. <br />Amount <br />$26.50 Per Hour not to exceed $29,000.00 <br />Increase of $4,000.00 <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />ired For Change Orders <br />Amount of <br />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 Original <br />® ❑ Michael Divita <br />® ❑ Toy Villa <br />❑ ❑ <br />