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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/31/16 <br />Name Toy Villa Department Engineering <br />BPW Date 11/08/16 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ❑ <br />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 El <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />❑ <br />Agreement <br />Professional Services <br />❑ Contract ❑Pro osal <br />p ❑Addendum <br />❑ Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ❑ Re to Advertise <br />❑ Quote Award q' Title Sheet <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />�q <br />Other: Amendment <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 />mequirea information <br />MDale Clin erman <br />Yes No ❑ If Yes <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Com <br />One Way to Two Way Conver <br />116-001 <br />TIF Bond <br />Amend the original contract by extending the tern of the contract from <br />October 29, 2016, to November 30, 2016. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Michael Divita <br />MIR <br />For Chanqe Orders <br />Dispersal After <br />