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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 1-j N AIZ Uo <br />Name _baV)(kJU V-UIVYIQr <br />Department WnFaV67w \ (tkt(n <br />BPW Date d &b) X"J'(, <br />Phone Extension )(6i3\b <br />i <br />Required Prior to Submittal to Board <br />Legal <br />Attorney Name <br />WQ(\(\Ql S-AriYY11 t <br />Controller <br />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 �C] <br />Check the Appropriate Item Type <br />— Required for All Submissions <br />❑ <br />Agreement <br />❑ Contract <br />❑ Proposal 0 Addendum <br />'Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />El Bid Award <br />❑ Req. to Advertise ❑Title Sheet <br />El <br />Quote Opening <br />ElQuote Award <br />❑ <br />Change Order No. <br />❑ C/O & PGA No. <br />❑ PCA <br />❑ <br />Ease/Encroach. <br />Traffic Control <br />Company or Vendor Name Hsli <br />New Vendor ❑ Yeso No ❑ If Yes, Approved by Purchasing <br />MBEMBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name VAU(a VVOWA3� !Nnd._S\ACU nU �iY� ri�Y1rT <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />For <br />Dispersal After Approval <br />