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Date <br />Name <br />BPW Date <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />September 6, 2016 <br />David Relos Department <br />2016 <br />DCI <br />Phone Extension 5836 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name Ben Dougherty <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 />❑ 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. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />n Other: <br />I Required Information <br />Company or Vendor Name Board of Public Works <br />New Vendor <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 />Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE ❑ WBE <br />Establishing parking rates for publically owned parking facilities. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Onlv <br />Amount of ❑ Increase $ <br />❑ Decrease $ <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 />El <br />0 <br />® <br />❑ <br />® <br />❑ <br />:• <br />Ben Doughe <br />David Relos <br />