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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />1 /26/17 <br />Jen Hockenhull <br />Department A/F <br />BPW Date 02/14/2017 Phone Extension 9822 <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. <br />Ease/Encroach. <br />Other: <br />Contract <br />Resolution <br />Bid Award <br />Quote Award <br />C/O & PCA No. <br />Traffic Control <br />Proposal <br />❑ Req. to Advertise <br />sm <br />Company or Vendor Name H.J Umbaugh & Associates <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name Financial Assurance Test — IDEM Requirement <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />`i1..I . <br />General Fund —Admin Fin Budget <br />101-0401-415-31-06 <br />$ 5,000.00 <br />Due upon completion of contract <br />❑ Title Sheet <br />closed landfill. Umbaugh is able to perform the required assurances <br />which meet the needs of IDEM. <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment. E-Verifv. Iran, etc.) <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ❑ John <br />❑ ❑ <br />❑ ❑ <br />After Approval <br />