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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12-15-16 <br />Name <br />Kim Thompson <br />Department <br />Utilities <br />BPW Date <br />12-22-16 <br />Phone Extension <br />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 />❑ Agreement LJ Contract Ll Proposal Ll 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 />M Other: Invoice <br />Company or Vendor Name <br />New Vendor ❑ Yes Lx <br />MBE/WBE Contractor ❑ MBE [ <br />MBE/WBE Contractor Requested ❑ No <br />Project Name <br />Project Number <br />Funding Source Water Works O&M <br />Account No. 620-0640-657-36-02 <br />Amount $ 21,265 <br />Terms of Contract 3 yr, with Annual Pmts. Y1-$21,265, Y2-$21,795, Y3- <br />$22,340(Estimates based on products and services we have <br />Purpose/Description <br />Amount of <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />No ❑ If Yes, Approved by Purchasing <br />WBE <br />] Yes Name of Company <br />Required Contractor's Certification Form Attached (Non- <br />lusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran. etc <br />Copy <br />Original <br />® <br />❑ Kim Thompsor <br />® <br />❑ Dan O'Connor <br />❑ <br />❑ <br />