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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date May 7,,.._2019 .................... <br />Name Benjamin Dougherty Department Admin & Finance <br />1 9 Y.... .... ...... <br />a 14_ <br />BPW Date M, 2019 Phone Extension 7678 <br />Re uired Prior to Submittal to Board <br />Legal X Elliot Anderson <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ® and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ❑ <br />Check the <br />" Agreement <br />® Professional Services <br />[] Bid Opening <br />Quote Opening <br />El Chg Order No. <br />El Ease./Encroach. <br />I-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />wroor ate Item T oe — Reau red" for All Submissions <br />Proposal <br />[:] <br />Contract El <br />Amendment <br />E] <br />Bid Award <br />� <br />Quote Award <br />C/O & PCA No. ❑ PCA <br />❑ <br />Traffic Control � Resolution <br />Claim <br />Addendum <br />❑ Req. to Advertise ❑ Title Sheet <br />Re uired Information <br />Elizabeth Inks <br />Yes ® If Yes, Approved by Purchasing <br />❑ No <br />El MBE Completed E-Verify Form Attached <br />E] WBE <br />DFOIm lementation ..._... <br />None <br />Fund 404 COITIT .............................. ...... <br />404-0672-415.31-06 <br />�................. . <br />NTE $37,500 <br />El Yes <br />❑ No <br />Contract for professional services for participation and leadership <br />on DFO implementation team (post -retirement). <br />For Chang Orders Only <br />Amount of Increase $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Changer % <br />New Amount $ <br />Total Percent of Change: % <br />Time Extension: ..� <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />El <br />El <br />