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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/29/16 <br />Name Toy Villa Department Engineering <br />BPW Date 11/08/16 Phone Extension 5920 <br />L Kequired Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />I <br />Check the Appropriate Item Type —Required for All Submissions <br />❑ <br />❑ <br />Agreement <br />Professional Services <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Resolution <br />❑ <br />❑ <br />Bid Opening <br />Quote Opening <br />❑ Bid Award ❑ Re to Advertise <br />El Quote Award q' El Title Sheet <br />® <br />Change Order No. 3 <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />® <br />Other: Amendment <br />Required Information <br />Company or Vendor Name <br />Premium Concrete <br />New Vendor <br />❑ Yes N No ❑ If Yes Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of company <br />Project Name <br />2016 Curb and Sidewalk <br />Project Number <br />116-029 <br />Funding Source <br />MVH <br />Account No. <br />202.0619.431.31.06 <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of <br />Increase <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 />ired For Ch <br />$ 19,065, <br />419,726.70 <br />11.37% <br />Dispersal After Approval <br />Terri Swift <br />vma <br />