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BOARD OF PUBLIC WORKS <br /> AGENDA ITEM REVIEW REQUEST FORM <br /> Date July 16, 2015 <br /> Name Carl Littrell Department PW/Engineering <br /> BPW Date July 28, 2015 Phone Extension 5937 <br /> ar m°mac H <br /> al $" F z? . -n....,a'�.::,..'', sea oi;P:76780131n4iii. <br /> Legal X Attorney Name Ben Daugherty <br /> Controller X 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 X <br /> 0 Agreement 0 Contract • Proposal ❑Addendum <br /> ❑ Professional Services ❑ Resolution <br /> ❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br /> ❑ Quote Opening ❑ Quote Award <br /> ❑ Change Order No. ❑ CIO & PCA No. ❑ PCA <br /> ❑ Ease/Encroach. ❑ Traffic Control <br /> • Other: Vacation <br /> rs-}.T W ., s s,r UI i ' 2` ,u rat _ .- . -"J <br /> Company or Vendor Name <br /> New Vendor ❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br /> MBE/WBE Contractor ❑ MBE ❑ WBE <br /> MBE/WBE Contractor <br /> Requested ❑ No ❑ Yes Name of Company <br /> Project Name Main/Lafayette Connector <br /> Project Number 110-058 <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, Non-Discrimination, Non-Debarment, E-Ver' , Iran, etc. <br /> Amount of ❑ Increase $ <br /> ❑ Decrease $ <br /> Previous Amount $ <br /> Current Percent of Change: <br /> New Amount $ <br /> Total Percent of Change: (� <br /> f"`'�`� -s?^i rrsr.- a�'! .4l� �eri-F��Y`R%/A o Xi <br /> Copy Original <br /> X ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br />