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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/01/16 <br />Name Toy Villa Department Engineering <br />BPW Date 12/13/16 Phone Extension 5920 <br />Prior to Submittal to <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 />❑ <br />Check the Appropriate Item Type —Required for All Submissions <br />Agreement ❑ Contract ❑ Proposal <br />❑ <br />Professional Services ❑ Resolution P Addendum <br />❑ <br />❑ <br />Bid Opening ❑ Bid Award <br />Quote O enin ElReq, to Advertise ❑Title Sheet <br />P 9 ❑Quote Award <br />® <br />Change Order No. 1 ❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ 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 In <br />Walsh & Kelly, Inc. <br />❑ Yes ®No <br />❑ MBE ❑WBE <br />No I I Yes <br />of Com <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />I Required For Change Orders Only <br />Amount of ® Increase $ 7,479.85 <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />v� Dispersal After Approval <br />Roger Nawrot <br />Tov Villa <br />