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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />8/03/16 <br />Timmer <br />Department DCI <br />BPW Date 8/23/16 Phone Extension 5841 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type <br />— Required for All Submissions <br />❑ Agreement <br />® Contract <br />❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />❑ Other: Amendment <br />Information <br />Company or Vendor Name Department of Community Investment <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Requested ® No ❑ Yes Name of Company _ <br />ESG Administration Activity <br />16-JE-01 <br />Emeraencv Solutions Grant (ESG) <br />212.1001 <br />$ 2,000 <br />1/01/16 — 12/31/16 <br />Provide administrative services for the City's ESG funding <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment _ E-Verify Iran etc <br />Amount of I -I Increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />Love <br />uired For Chanae Orders <br />Dispersal After Approval <br />