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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/17/16 <br />Name Toy Villa l Department Engineering <br />BPW Date 10/25/16 Phone Extension 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. 4 ❑ 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 />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />red intormation <br />Walsh & Kelly, Inc. <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />r] MBE ❑ WBE <br />No ❑ Yes Name of <br />East Bank Sewer Separation — Phase 5 (Division B) Sewer Bond <br />114-062N R <br />Sewer Bond <br />429.1050.460.31.02 <br />Approval of Change Order #4 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of ® Increase $ 25,900.00 93 Dols <br />❑ Decrease $ <br />Previous Amount $ 5,279,000.66 <br />Current Percent of Change: 0.49% <br />New Amount $ 5,304,900.66 <br />Total Percent of Change: 4.41 % <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Aaron Kobb, Judy Love, Beth Leonard <br />ME <br />