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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />February 21, 2017 <br />Tara Weigand <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date February 28, 2017 Phone Extension 5998 <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 Appropriate Item Type — Required for All Submissions <br />❑ Agreement Amendment <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />I-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <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 Chanoe: <br />Copy <br />Original <br />® <br />❑ Kara Boyle <br />® <br />❑ Roger Nau <br />® <br />❑ Terri Swift <br />red Information <br />202-0619-431.23-03, .23-21, .23-24 <br />640-0620-811.22-24, .23-24 <br />641-0621-792.22-24, .23-02, .23-03, .23-04 <br />641-0625-792.22-24, .23-04 <br />Unit Price <br />Purchase of materials for Street and Sewer Departments <br />LJ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />For Chance Orders On <br />I After Approval <br />