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4/14 11 Jenni er orle - Agenda Request Form- Herceg.doc - Wage 11 <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Aril 14, 2011 <br />Department <br />Engineering <br />BP Date <br />April 25, 2011 <br />Phone <br />235 -5933 <br />Name <br />John Engstrom <br />Requirj Legal 1Z Attorney Name <br />ed Controller 7 Controller review is required for all Contracts $5,000.00 or more <br />Prior and greater than one year in length per the City Purchasing <br />to Policv <br />5ubmi I Other Appropriate Reviewers <br />ttal to <br />Board <br />Check the A propriate Item Type - Required for All Submissions <br />A reement DI-Contract IXPro osal 17 Addendum <br />E Claim <br />0 Bid Opening u Bid Award 1? Reg. to Advertise I n Title Sheet <br />u Quote Opening -1-1 Quote Award <br />L Chg Order No. u C/O & PCA No. 17 PCA <br />L Ease. /Encroach. 11 Traffic Control 17 Resolution <br />rl Other: <br />Required Information <br />Company or Vendor Name Ken Herceg & Associates /Revised from last meeting <br />New Vendor []Yes 19 No 0 If Yes, Approved by Purchasing <br />Pro'ect Name Training Center Sewer & Water Extensiont <br />Proiect Number 109 -011A <br />Funding Source EMS Capital Fund <br />Account No. E.M.S.C.I.P. #288000- 341 -03 -00 <br />Amount $ 15,000 <br />Terms of Contract <br />Purpose /Description Engineering services to extend sewer and water to the <br />southeastern corner of the proposed Training Center <br />For Chanae Orders Only <br />Amount of L Increase $ <br />U Decrease $ <br />Previous Amount $ <br />Current Percent of % <br />Change: <br />New Amount $ <br />Total Percent of Change: I % <br />PO No. <br />Dispersal After Approval -- <br />Copy Original - <br />n I� <br />L L <br />