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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST' FORM <br />Date 12/6/17 Department <br />Name Kara Boyles Division/Bureau <br />Public Works <br />Engineering <br />BPW Date 12121/17 Phone Extension 5933 <br />Required PCiorto 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 <br />NESEM = <br />F1 Agreement <br />Ll Contract ❑ Proposal L] Addendum <br />F-1 Professional Services <br />F-1 Resolution <br />Eli <br />Bid Opening <br />El Bid Award E:I'Req. to Advertise ❑ Title Sheet <br />F-1 <br />Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />El <br />Traffic Control: <br />Other: Reiect Quotes, <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />MBEIWBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />El Yes [:] No F-1 If Yes, Approved by <br />Purchasinq <br />L MBE L WBE <br />1 1 No F-1 Yes Name of Comoanv <br />Lafayette Building Roof <br />117-100 <br />H Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <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 />El <br />F1 <br />F-1 <br />F-1 <br />El <br />1-1 <br />