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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />9/6/2016 <br />Public Works <br />Engineering <br />BPW Date 9/13/2016 Phone Extension 5796 <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 />Nadia Correa <br />Department <br />Division/Bureau <br />Purchasing ® <br />George King <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />Professional Services <br />❑Contract ❑ Proposal ❑ Addendum <br />❑ Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />® <br />Change Order No. 1 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />I —I <br />Other: <br />Required Information <br />Company or Vendor Name Premium Concrete <br />New Vendor n Yes 6ZI No n if y.� Annrnvo l by o, , h��: o <br />MBE/WBE Contractor ❑ ME <br />MBE/WBE Contractor Requested ❑ No <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />2016 Curb a <br />116-029 <br />MVH <br />202-0619-431 <br />Extra sidewa <br />of <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Only <br />Amount of ® Increase $ 46872.20 <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Cha <br />Copy <br />Origin <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />359750.00 <br />