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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />10/07/2019 <br />Maricela Juarez <br />Department Admin & Finance <br />BPW Date 10/22/2019 Phone Extension 9953 <br />INIIIIIIIIIIIIIIIIIIIIYIIP✓�U �fr"kNrfIHHNNNkkH�✓FlbMt�,nNN4hH5nfi'rt4/N,aass�le�f .. '�&W'BM IVWIIW4W4WIVWIIMWIVW.4N9NWNYFYpWIVWWIVNNfWI� �++�YHHHy,�W,V,W,W,y�y�y�y�y�y�y�y�y�yN�l'M'NW�V�V�V�V�V�V�V�VWN'MIBY :Ad ' f6J°J{4'rflA1�014'ftuNPld'AI'dN1XIIIIIIIIIIIIIIIIIIIIWIIIIIIIIC <br />Required Prior to Submittal to Board <br />Legal Attorney Name <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller ❑ and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing 0 <br />Check the p <br />LJ Agreement <br />El Professional Services <br />Ej Bid Opening <br />Quote Opening <br />El Chg Order No. <br />R Ease./Encroach. <br />F7, Other: Disposal <br />Topriate Item Type — <br />Contract <br />❑ Amendment <br />E Bid Award <br />F] Quote Award <br />El C/O & PCA No. — <br />El Traffic Control <br />Company or Vendor Name <br />New Vendor ❑ Yes <br />❑ No <br />MBE/WBE Contractor MBE <br />WBE <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />red Information <br />PCA <br />Resolution <br />Claim <br />If Yes, Approved by Purchasing <br />Addendum <br />❑ Title Sheet <br />Completed E-Verify Form Attached El Yes <br />No <br />ForChang Orders h. _�mm <br />$ <br />Amount of increase <br />E] Decrease $ <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />El <br />