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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/17/17 <br />Name Michelle Smith Department Utilities/Water&WW <br />BPW Date 3/28/17 Phone Extension 5994 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller El greater <br />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 />Company or Vendor Name Perkin Elmer <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested El No ❑ Yes Name of Company <br />Project Name f� LO-6 eiwip <br />Project Number 11 <br />Funding Source Water Works Operating Fund & Wastewater O&M <br />Account No. 620.0640.603.31.35 ($9700) & 641.0630.793.63.3 <br />Amount $ 13,737.00 <br />Terms of Contract 1 Year, 4/1/17 — 3/31/18 <br />Purpose/Description Manufacturer Service Agreement <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion Non -Discrimination Non -Debarment E-Verify,Iran etc.) <br />Required For Change Orders Onl <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 />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Dispersal After Approval <br />Carol Kurzhal <br />Roxanne Lawson <br />Michelle Smith <br />