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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />11/15/16 <br />Public Works <br />Engineering <br />BPW Date 11/22/16 Phone Extension 5903 <br />Kevin Fink <br />Department <br />Division/Bureau <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name: Michael Schmidt <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 />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control: <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />Ziolkowski Construction, Inc. <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No Yes Name of Company <br />Project Name <br />2016 Curb and Sidewalk Construction Phase II <br />Project Number <br />116-029A <br />Funding Source <br />MVH <br />Account No. <br />202-0619-431.31-06 <br />Amount <br />Division E: $ 32,8Q8.00 <br />Division F: $ 35,6.00 <br />Division G: $ 14,586.00 <br />Division H: $ 14,959.00 <br />Division I: $ 37,360.00 <br />Total Amount: $ 135.408.00 <br />Terms of Contract <br />Purpose/Description <br />Not to Exceed Unit Prices <br />Award each <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />ired For Chance Orders <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Copy Original <br />® ❑ Roger Nawrot <br />® ❑ Kevin Fink <br />