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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 21, 2017 <br />Name David Relos <br />Department DCI <br />BPW Date March 28, 2017 <br />Phone Extension 5836 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />® Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />❑ Other: <br />Required Information <br />Company or Vendor Name <br />Bruce D. Majeski <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/1NBE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />Fire Station # 9 <br />Project Number <br />Funding Source <br />EMS Operating <br />Account No. <br />287-0902-422-42-01 <br />Amount <br />$ 80,000 <br />Terms of Contract <br />Purchase Agreement & Uniform Acquisition Offer <br />Purpose/Description <br />Acquisition of property at 914 21st St. <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 />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />® ❑ BPW <br />® ❑ Michael <br />Schmidt <br />❑ ® David Relos (for closing) <br />