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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/29/16 <br />Name Toy Villa <br />tip% Department Engineering <br />BPW Date 11/08/16 <br />Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal <br />❑ Attorney Name <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 <br />❑ <br />Check the <br />Appropriate Item Type —Required for All Submissions <br />❑ <br />❑ <br />Agreement <br />Professional Services <br />❑ Contract ❑ l Pro osa <br />p El Addendum <br />❑ Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award <br />❑ Quote Award ❑ Req. to Advertise Title Sheet <br />® <br />Change Order No. 2 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <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 />Required Information <br />Concrete <br />No If <br />No ❑ Yes Name of <br />2016 Curb and Sidewalk <br />116-029 <br />iwvri <br />202.0619.431.31.06 <br />Amount $ <br />Terms of Contract <br />Purpose/Description ❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Oniv <br />Amount of 29 <br />Increase <br />❑ <br />Decrease <br />Previous Amount <br />$ 4C <br />Current Percent of Change: <br />3.22 <br />New Amount <br />$ 41 <br />Total Percent of Change: <br />16.6 <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />Terri Swift <br />Toy Villa <br />13.1 <br />uispersal Atter Approval <br />