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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 05/07/2019 Department Public Works <br />Name Roger. .... Nawrot ..........................._.. <br />Division/Bureau Engineering <br />BPW Date 05/14/2019 Phone Extension 5932 <br />�-- °--�r����mmmmr�xi��r imm��� � . ,... �w�wnn�romvinnwmimn�mavnww:w.��arnmmwnH�,�animi��mmmuwuwuwuww�w!��u!��uw.wwwwu�wuwwu�w!uu�wmimimmmuuuuuumuumWuumWuuuuuuuuuuuuumWuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuumWuumWmWmWuuuuz <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 El <br />Check the <br />LJ Agreement <br />E] Professional Services <br />j Bid Opening <br />Quote Opening <br />Change Order No. 2 <br />❑ Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />w priatevItem i" r e <br />D Contract <br />Resolution <br />Bid Award <br />Quote Award <br />E] C/O & PCA No. <br />❑ Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />ired" for All Submissions <br />El Proposal .......���.. <br />Required Information <br />Req. to Advertise <br />PCA <br />Brown & Brown General Contractors, Inc.. <br />Addendum <br />❑ Title Sheet <br />Approval of C.O #2 per order and instruction of the SBFD Fire <br />Marshall for the occuoancv permit. <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion Non -Discrimination, Non -Debarment, EVerm�„ Iran, etc. <br />- __---_. _ » � �. _ ......_...._ ^ �...w..__.�..�....MM_..._�.. <br />Ong......_.. _..... �_...�_.n.w�......__ - uired For Change Orders..... _...mm.mmmmmm�.. ........ �.w_w.�.. <br />Amount of ® Increase $ 7,911.00 <br />El Decrease .............$ <br />Previous Amount $ 88.4.1..4...0.................................................m..m_ <br />Current Percent of Change. 8.95% <br />New Amount $ 96,325.00��� <br />Total Percent of Chaff e w 2 <br />Dispersal After Approval <br />Copy <br />Original <br />