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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/10/16 <br />Name Toy Villa Department Engineering <br />BPW Date 11/22/16 Phone Extension 5920 <br />I <br />Required Prior to Submittal to Board l <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 />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. 2 Final ❑ 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 />Amount <br />Terms of Contract <br />Purpose/Description <br />Required Information <br />Martell electric, LLC <br />❑ Yes No ❑ If Yes Approved by Purchasi <br />I -I MBE I -I WBE <br />LJ No ❑ Yes Name of Company <br />2016 Yard Lamppost Prooram <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non-Dehnrmant F-Verifv Iran Af, <br />For C <br />Amount of ❑ Increase $ <br />® Decrease $ 1,000.00 <br />Previous Amount $ 21,250.00 <br />Current Percent of Change: 4.71 % <br />New Amount $ 20,250.00 <br />Total Percent of Change: 80.20% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Kevin Fink <br />® ❑ Toy Villa <br />❑ ❑ <br />On <br />