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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />'16 <br />Timmer <br />Department DCI <br />BPW Date 7/26/16 Phone Extension 5841 <br />I Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <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 />Check the Appropriate Item Type — Required for All Submissions <br />® <br />Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ Quote Award <br />❑ <br />Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ Traffic Control <br />❑ <br />Other: Amendment <br />Kequirea mtormation <br />Company or Vendor Name Department of Community Investment <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name Administration of Supportive Housing Rental Assistance Grant <br />Project Number 16-JS-01 <br />Funding Source Continuum of Care (CoC) <br />Account No. 212.1001.460.39.30 <br />Amount $ 2,000 <br />Terms of Contract 3/01/16 — 2/28/17 <br />Purpose/Description Fund costs of administering Oaklawn's SHRA grant <br />® Required Contractor's Certification Form 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 />Love <br />Dispersal After Approval <br />