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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />07/25/2016 <br />Brent Hussung Department Utilities <br />BPW Date 08/01/2016 Phone Extension 5512 <br />Legal Attorney Name 1W� G�lq�2 Sc1 /J 7— <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ] <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />Other: Amendment <br />Company or Vendor Name <br />U.S. <br />New Vendor ❑ Yes F <br />MBE/WBE Contractor ❑ MBE [ <br />MBEM/BE Contractor Requested ❑ No <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />No ❑ If Yes, Approved by Purchasing <br />WBE <br />Yes Name of Company <br />O&M <br />620-0640-603-32-04 <br />$ 177/mo <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Increase <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />