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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />March 21.2017 <br />David Relos <br />Department DCI <br />BPW Date March 28, 2017 Phone Extension 5836 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller El greater <br />review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />® Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />❑ Other: <br />Required Information <br />or Vendor Name <br />Bruce D. Majeski <br />New Vendor <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBEM/BE Contractor <br />❑ MBE ❑ WBE <br />Project Name <br />Fire Station # 9 <br />Project Number <br />Funding Source <br />EMS Operating <br />Account No. <br />287-0902-422-42-01 <br />Amount <br />$ 80,000 <br />Terms of Contract <br />Purchase Agreement & Uniform Acquisition Offer <br />Purpose/Description <br />Acquisition of property at 2104 Mishawaka Ave. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verif , Iran, etc. <br />Required For Change Orders Only <br />Amount of ❑ <br />❑ <br />Increase $ <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % <br />New Amount <br />$ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />® ❑ <br />BPW <br />® ❑ <br />Michael Schmidt <br />❑ ® <br />David Relos (for closing) <br />