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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date January <br />12, 2017 <br />Name Matthew Bussell Department Utilities <br />BPW Date February <br />14, 2017 Phone Extension 5670 <br />Required Prior to Submittal to Board <br />Legal <br />® Attorney Name Michael Schmidt <br />Controller <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />❑ <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ <br />Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services ❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor <br />Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Granular Activated Carbon Re -Activation and Virgin Replacement <br />Project Number <br />Funding Source <br />Loss Recovery Fund 227 <br />Account No. <br />227.0640.601.39.55 <br />Amount <br />$ <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 />❑ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total Percent of Change: % / <br />Dispersal After Approval <br />Copy Original <br />® ❑ <br />Matthew Busse[] <br />® ❑ <br />Brad VanOosterum <br />® ❑ <br />Kim Thompson <br />