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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 09/05/16 <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 <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 />F- Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />Walsh & Kelly, Inc. <br />LJ Yes ® No ❑ If Yes, Approved by Purchasing <br />❑ MBE ❑ WBE <br />No <br />of <br />East Bank Sewer Separation — Phase 5 (Division B) Sewer Bond <br />114-062A <br />Sewer Bond <br />429.1050.460.31.02 <br />s <br />Approval of Change Order #3 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />For Change Orders O <br />Amount of N Increase $ 25,200.00 <br />❑ Decrease $ <br />Previous Amount $ 5,253,800.66 <br />Current Percent of Change: 0.48% <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ❑ Aaron Kc <br />® ❑ Roger M <br />® ❑ Toy Villa <br />3.90% <br />Dispersal After <br />Love, Beth Leonard <br />