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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 1/9/17 <br />Name Michelle Smith Department Lltility/Water Works <br />BPW Date 1/27/17 Phone Extension 5994 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Aoorooriate Item Tvne — Reauirad fnr All .4nhrnfscinnc <br />JXJ Agreement U Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />I-1 Other: <br />Company or Vendor Name U.S. Geological Sur <br />New Vendor ❑ Yes ®No <br />MBEM/BE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />If Yes, Approved by Purchasing <br />Name of Company <br />eement for Water f <br />GC17NF0000201X2 <br />_Water Works Operational Fund <br />620.0640.658.31.35 <br />$ 3000.00 <br />ns <br />Required Contractor's Certification Form Attached (Non- <br />Non-Discrim <br />Amount of I I 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 Original <br />❑ ® Paul Buszka <br />® ❑ Roxanne Lawson <br />® ❑ Michelle Smith <br />Iran <br />