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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 19, 2017 <br />Name Tara Weigand <br />Department <br />JDA—WILGA-FAkaAft <br />Public Works <br />Engineering <br />BPW Date December 21, 20117 Phone Extension 5998 <br />Required 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 Z <br />H Agreement Amendment <br />F-1 Professional Services <br />❑ Bid Opening <br />F1 Quote Opening <br />0 Change Order No. <br />E] Ease/Encroach. <br />F-11 Other: <br />Company or Vendor Name <br />H Contract H Proposal L] Addendum <br />0 Resolution <br />0 Bid Award El Req. to Advertise El Title Sheet <br />Z Quote Award <br />F-1 C/O & PCA No. F-1 PCA <br />n Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBEANBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Asphalt Restoration Services, LLC <br />El Yes FRI No F-1 If Yes, Approved by <br />Purchasing <br />El MBE F1 WBE <br />n No F1 Yes Name of Company <br />2017 Crack Sealing <br />117-102 <br />LRSA - Street Maintenance <br />251-0608-431.36-10 <br />$85,000.00 <br />Unit Prices <br />Asphalt crack sealing and filling at various locations <br />ff Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of 0 increase $ <br />F] Decrease $ <br />Previous Amount $ <br />Current Percent of Change: °r'® <br />New Amount <br />Total Percent of Change: % <br />Copy <br />Original <br />M <br />0 Roger Nawrot, Assistant City Engineer <br />M <br />F-1 Derick Roberts, Streets Department <br />F <br />El <br />