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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 06/28/16 <br />Name Toy Villa <br />BPW Date 071WI16 <br />Department <br />Phone Extension <br />Engineering <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller El greater <br />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 />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. 1 ® C/O & PCA No. 1 Final ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <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 Information <br />TGB Unlimited d/b/a S/T Bancroft <br />❑ Yes ® No ❑ If Yes, Apl <br />❑ MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Colfax Avenue and Hill Street Improvements - Division A <br />114-018A <br />RWDA TIF <br />429.1050.460.31.02 <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc <br />I Reauired For Chanae Orders Only I <br />Amount of LJ Increase $ <br />® Decrease $ 13,342.25 <br />Previous Amount $ 137,523.68 <br />Current Percent of Change: 9.70% <br />New Amount $124,181.43 <br />Total Percent of Change: 9.70% <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ David Relos <br />® <br />❑ Judy Love <br />❑ <br />❑ Toy Villa <br />