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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />12/13/2018 <br />Alicia Czarnecki <br />p En. <br />Department Engineering <br />�. �....................» <br />BPW Date 12/20/2018 Phone Extension 5903 <br />N41' " ONIN9M9WI1NVd'WdMfi'M��� IIIIIIIIIIIIIIIIIIIIIIIIIIIIIImmmIIIIIIIIW iI NIMI A@'@IV@W@@WM NNVYMONMWiGiNIMRMOIdN1V@Hlq ImImIImIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ii v#ee// <br />� . ........ R �� iredITPriorto Submittal toWBoard <br />Legal ® Attorney Name Clara M'cDani'els <br />Controller ® 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 ® Michael Schmidt <br />Check the <br />[_I Agreement <br />E Professional Services <br />El Bid Opening <br />El Quote Opening <br />Change Order No. <br />Ease/Encroach. <br />Other: <br />1ropriate Item mType — <br />01 Contract <br />El Resolution <br />❑ Bid Award <br />El Quote Award <br />El C/O & PCA No, <br />El Traffic Control <br />for All Submissions <br />oposal .__ Add......__._ <br />Pr Addend um <br />❑ Req. to Advertise ❑ Title Sheet <br />fired Information <br />❑ PCA <br />Company or Vendor Name Herman and Goetz Inc.. <br />New Vendor ❑ Yes E No El If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE [:] WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name Fire Station 10 and 11 Equipment <br />www _A............. <br />Project Number 118 108 <br />Account <br />No20902 422 43-10 <br />Amount$4..................... <br />FundingSourceurce 871Purchases /Materials &Equipment <br />�.�.......�.......� _....... _.m <br />7,287.00 <br />Terms of Contract <br />Purpose/Description <br />Provide and install gear extractor and soap dispensing system at <br />Fire Stations 10 and 11, <br />Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment., E-Verify, Iran, etc.) <br />----- <br />ired For Change Orders On <br />Amount of Increase $ <br />❑ Decrease <br />Previous Amount $ u <br />............................... <br />Current Percent of Change: <br />New Amount $ <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy <br />Original <br />❑ <br />❑I <br />