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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />07/05/16 <br />Toy Villa i� Department Engineering <br />BPW Date 07/12/16 Phone Extension 5920 <br />to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Required for A// Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />® C/O & PCA No. 1 Final ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />L.L.Geans Construction Co. <br />New Vendor <br />❑ Yes N No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Compan <br />Project Name <br />Colfax Avenue and Hill Street Improvements <br />Project Number <br />114-018B <br />Funding Source <br />RWDA TIF <br />Account No. <br />429.1050.460.31.02 <br />Amount <br />$ <br />Terms of Contract <br />Purpose/Description <br />Project Closeout <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran. et( <br />I Required For Change Orders Only <br />Amount of ® Increase $ 2,697.60 <br />❑ Decrease $ <br />Previous Amount <br />104.00 <br />Current Percent of Change: 4.34% <br />New Amount $64,801.60 <br />Total Percent of Change: 12.65% <br />Dispersal After Approval <br />Copy Original <br />® ❑ David Relos <br />® ❑ Judy Love <br />❑ ❑ Toy Villa <br />