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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 20, 2017 <br />Name Bob Krol Department Utilities- Water <br />BPW Date February 28, 2017 Phone Extension 5660 <br />Required Prior to Submittal to Board <br />Legal x Attorney Name Michael Schmidt <br />Controller x 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 x <br />unecK the Appropriate Item I ype — Kequired for All Submissions <br />Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award x 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 />Required Information <br />Company or Vendor Name <br />New Vendor <br />❑ Yes x No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ <br />WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Ductile Iron Pipe, Gate Valves, & Fire Hydrants <br />Project Number <br />Funding Source <br />Water Works Operating Fund and Capital Fund <br />Account No. <br />620-0640-606.23-62 and 620-0640-661.46-04 <br />Amount <br />660—' <br />Terms of Contract <br />One year from date of award with option for one year extension <br />Purpose/Description <br />Bid material purchase of various sizes of pipe valves hydrants <br />Amount of <br />Increa <br />Decree <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />❑ x <br />x ❑ <br />x ❑ <br />Roxanne <br />Kim Thor <br />Bob Krol <br />x Required Contractor's Certification Form Attached (Non -Collusion, <br />Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />.Required For Chanae Orders Onlv <br />