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Date <br />BPW Date <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />6/1/2018 <br />6/12/2018 <br />Department Fire <br />Phone 9255 <br />Name Andy Myer, Assistant Chief, EMS <br />o Legal ® Attorney Name Elliott Anderson <br />v o ro Controller review is required for all Contracts $5,000.00 or more <br />5 o � (0 Controller ® and greater than one year in length per the City Purchasing <br />Cr E m Policy <br />co Purchasing ® Michael Schmidt <br />Cheek the Appropriate Item Type — Required forAh Submissions <br />❑ <br />Agreement <br />❑ Contract <br />❑ Proposal <br />❑ Addendum <br />❑ <br />Claim <br />❑ <br />Bid Opening <br />® <br />Bid Award <br />❑ Req. to Advertise <br />❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Chg Order No. <br />❑ <br />CIO & PCA No. <br />❑ <br />PCA <br />❑ <br />Ease./Encroach. <br />❑ <br />Traffic Control <br />❑ <br />Resolution <br />❑ <br />Other: <br />Required .. morrnation <br />Company or Vendor Name <br />Ph sio Control <br />New Vendor <br />❑ <br />Yes ® <br />No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ <br />MBE ❑ WBE <br />Project Name <br />Project Number <br />Funding Source <br />EMS Capital Fund -Equipment Purchase <br />Account No. <br />287.0902,422.43-10 <br />Amount <br />$ 208,147.92 <br />Terms of Contract <br />As invoiced, net 30 <br />Purpose/Description <br />New monitors will replace older monitor/defibrillators <br />For Change' Orders Only <br />Amount of <br />❑ <br />❑ <br />Increase <br />Decrease <br />$ <br />I $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />PO No. <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />