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Date <br />Name <br />BOARD OF PUBLIC WO1UKS <br />AGENDA ITEM REVIEW REA QUEST FORM <br />December 18, 2017 <br />Tara Weigand <br />Department <br />Division/Bureau <br />Fl• <br />Engineering <br />BPW Date December 21, 20117 Phone Extension 5998 <br />Required Prior to Submittal to Board <br />Legal F] 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 F] <br />[] <br />Agreement Amendment <br />H Contract LJ Proposal Ll Addendum <br />El <br />Professional Services <br />n Resolution <br />n Bid Opening <br />El Bid Award ❑ Req. to Advertise El Title Sheet <br />F1 Quote Opening <br />Z <br />Quote Award <br />F1 Change Order No. <br />F1 <br />C/O & PCA No. ❑ PCA <br />[:] Ease/Encroach. <br />R Traffic Control: <br />F1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBEANBE 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 L Increase <br />El Decrease <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Chanae: <br />Copy <br />Original <br />i"! <br />S au �n <br />El Yes F1 No,❑ If Yes, Approved by <br />Purchasing <br />El MBEE] WBE <br />F-1 No F-1 Yes Name of Company <br />CenturV Center Fire Pump Replacement <br />117-038 <br />Hotel -Motel Tax <br />7304.420110.000.0099 <br />�T q �D9. ­ $4 (, S—, 0 C) <br />Replace the fire pump and jockey pump at the Century Center <br />[J Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Tom Cook, M/E Designs <br />Scott Herczeg, Century Center <br />