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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 02-06-2017 <br />Name Daniel O'Connor Department Innovation <br />BPW Date 02/14/2017 Phone Extension 6201 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />® Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />Diane Vill <br />New Vendor <br />® Yes [ <br />MBE/WBE Contractor <br />❑ MBE [ <br />MBE/WBE Contractor Requested ❑ No <br />Project Name <br />Project Number <br />Funding Source <br />Innovati <br />Account No. <br />279-06-1 <br />Amount <br />$ 3,500 <br />Terms of Contract <br />02/14/21 <br />Purpose/Description <br />ADSI Tr <br />Amount of <br />No ❑ If Yes, Approved by Purchasing <br />WBE <br />] Yes Name of Company <br />Professional Services <br />115-31-06 <br />— 04/30/2017 <br />1�9 Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Chanae Orders Only <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 />Dispersal After Approval <br />Daniel O'Connor <br />John M <br />