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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/6/2018 <br />Namele Silveus Department Engineering .. <br />BPW Date 11/13/2018 Phone Extension 9083 <br />HIN0111 <br />. . . .................. . ... <br />... Required Prior to Submittal to Board <br />Legal ❑ Attorney Name Clara McDaniels <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 Michael Schmidt <br />Check the <br />F-1 Agreement <br />E] Professional Services <br />F-I Bid Opening <br />Quote Opening <br />Change Order No. 1 <br />❑ Ease/Encroach, <br />F-1 Other: <br />)ropriate Item Type- <br />El Contract <br />[] Resolution <br />El Bid Award <br />El Quote Award <br />n C/O & PCA No. <br />El Traffic Control <br />for All Submissions <br />Proposal <br />E] Req. to Advertise <br />uired Information <br />El PCA <br />Company or Vendor Name Ziolkowski Construction, Inc, <br />New Vendor R Yes Z No [:] If Yes, Approved by Purchasing <br />MBE/WBE Contractor R MBE R WBE <br />MBEA1VBE Contractor Requested E No R Yes Name of Company <br />Project Name Erskine Clubhouse Renovation <br />Project Number 116-108 <br />Funding Source <br />Account No. <br />Addendum <br />El Title Sheet <br />Amount <br />Terms of Contract Eliminate intermediate Phase I Completion date of 11/30/18 (Final <br />Completion stags the same) . ... . <br />Purpose/Description Amendment to Substantial Completion Date, <br />F] Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc) <br />Required For Change Orders Only mmm <br />Amount of El increase $ . .............................. ... <br />1:1 Decrease <br />Previous Amount <br />Current Percent of Change: % ........ . . . ........ .... . ........ New Amount <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />Kyle Silveus <br />.. ..... ...... <br />Patrick Sherman <br />. . . . . . ......... El <br />