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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/15/16 <br />Name Toy Villa 1 Department Engineering <br />BPW Date 11/22/16 Phone Extension 5920 <br />I <br />Required Prior to Submittal to Board <br />Legal ❑ <br />Attorney Name <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for Ail Submissions <br />❑ <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />'Quote Opening <br />® Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ® No ❑ <br />If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />12'h Floor Remodel <br />Project Number <br />116-125 <br />Funding Source <br />Other Professional Services <br />Account No. <br />101.0501.415.31.06 <br />Amount <br />$ , � —F, S-73 <br />Terms of Contract <br />Purpose/Description <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 />Amount of <br />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 />0 <br />Anne Fuchs <br />Villa <br />After Approval <br />