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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />2/1/17 <br />Jen Hockenhull <br />Department A/F <br />BPW Date 2/14/17 Phone Extension 9822 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />LJ Agreement U Contract LJ Proposal LJ Addendum <br />® Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />Other: <br />Company or Vendor Name Peters Municipal G <br />New Vendor ® Yes ❑ No <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes <br />Project Name Financial Consult <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />If Yes, Approved by Purchasing <br />Name of Company <br />General Fund <br />101-0401-415-31-06 <br />$ 8,000 NTE <br />Upon Completion <br />Review proiected tax revenues <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc.) <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 />John <br />