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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/01/2017 <br />Name Amy Shirk, Senior Budget Analyst Department Admin & Finance <br />BPW Date 12/12/2017 ---Phone Extension 9133 <br />Requir -1d Prior to Submittal to Board <br />Legal Attorney Name <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 EJ <br />F-1 Agreement❑C ntract Proposal Ll Addendum <br />F] Professional Services �Xresolution V <br />F-1 Bid Opening x'_'%Bid Award Req. to Advertise El Title Sheet <br />EJ Quote Opening F-1 Quote Award01T - <br />n Change Order No. n C/O & PCA No. ❑ P,CA <br />F] Ease/Encroach. F-1 Traffic Control <br />M Other: Disposals <br />Company or Vendor Name <br />New Vendor El Yes 0 No El If Yes, Approved by Purchasing <br />MBEANBE Contractor F MBE F-1 WBE <br />MBEWRE Contractor Requested El No R 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 <br />Required Contractor's Certification Form Attached (Non - <br />Collusion, INon-Discrim !nation, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of H Increase <br />F-1 Decrease <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />El <br />El <br />n <br />n <br />n <br />F-1 <br />E5 <br />