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BOARD OF PUBI,IC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 8/14/2018 Department Public Works <br />Name Toy Villa Division/Bureau Engineering <br />BPW Date 8/28/2018 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />Legal F-1 Attorney Name: <br />Controller El 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 El <br />0 Agreement F] Contract LJ Proposal L] Addendum <br />E] Professional Services El Resolution <br />F� Bid Opening F-1 Bid Award El Req. to Advertise ❑ Title Sheet <br />F-1 Quote Opening F Quote Award <br />Z Change Order No. 3 F-1 C/O & PCA No. ❑ P CA <br />Ease/Encroach. Traffic Control; <br />❑ Other: <br />Company or Vendor Name <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 />Amount of F-1 increase <br />n Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />F-1 <br />F-1 <br />1-1 <br />11 <br />El <br />1-1 <br />C & E Excavating , Inc. <br />Q Yes Z No El If Ye§, Approved b y <br />[:1 MBE E] WBE <br />[J No [:1 Yes Name of CqMpAg <br />Ironwood Drive Pavement Rehabilitation and Intersection <br />117-071A <br />Local Road & Bridge� Grant <br />265.0608.431.36.10 <br />Approval of C.O. #3 - Time Extension <br />F-1 Required Contractor's Certification Forms Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />After Aivroval <br />