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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />10-29-16 <br />Kim Thompson Department Utilities <br />BPW Date 11-8-16 Phone Extension 5969 <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 — 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 />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Informatio <br />Company or Vendor Name <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name North Station Well #1 Replacement Design <br />Project Number 16W001 <br />Funding Source Water Works Construction Engineering <br />Account No. 622.0640.661.31.02 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Required Contractor's Certification Form Attached (Non - <br />For Change Orders On <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />