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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 4/7/17 <br />Name <br />Donna Hanson <br />Department <br />Engineering <br />BPW Date <br />4/11/17 <br />Phone Extension <br />9254 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name 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 />YIZI Agreement <br />N Contract LJ Proposal Lj Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />E] Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />F] Other: <br />Company or Vendor Name Dou las Max <br />New Vendor ❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBEIWBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount $ <br />Terms of Contract <br />Purpose/Description Contract for count sewer connection to City sanita sewer line <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 />Copy <br />Original <br />❑ <br />❑ <br />% <br />Dispersal After Approval <br />