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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date _09/20/16 <br />Name <br />Toy Villa <br />Department <br />Engineering <br />BPW Date <br />09/27/16 <br />Phone Extension <br />5920 <br />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. ® C/O & PCA No. 3 Final ❑ 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 />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />required Intormation <br />Walsh & Kelly, Inc. <br />❑ Yes ®No ❑ If Yes <br />I -I MBE I -I WBE <br />U No ❑ Yes Name of Company <br />Hill St. & Colfax Ave. On Site Improvements <br />113-033 <br />SBCDA TIF <br />420.1050.460,42.03 <br />z <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc. <br />Increase $ <br />Decrease $ 5,190.91 <br />Previous Amount $ 187,906.20 <br />Current Percent of Change: 2.76% <br />New Amount $ 182,715.29 <br />Total Percent of Change: 9.49% <br />Copy <br />Original <br />® <br />❑ Jitin <br />® <br />❑ Rog <br />® <br />❑ Toy <br />fE <br />Change Orders <br />Uispersal After Approval <br />Judy Love <br />