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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/29/16 <br />Name <br />Bussell, Matthew <br />Department <br />Utilities/Water Works <br />BPW Date <br />7/12/2016 <br />Phone Extension <br />5670 <br />I Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <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 ❑ <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 />F1 Other: <br />Company or Vendor Name <br />Zimmerman <br />Information <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ® No ❑ Yes Name of Company <br />North Station Filtration Plant Vessel #5 Raw Water SS pipe <br />Project Name replacement <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Water Works Operating Fund <br />620.0640.602.36.05 (Labor);620.0640.604.23.10 (Materials) <br />Labor $9,208.00, Materials $22,677.50, Total $31,885.50 <br />Required Contractor's Certification Form Attached (Non- <br />usion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />ired For Change Orders <br />Amount of H Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />❑ <br />0 <br />Dispersal After Approval <br />Matthew Bussell <br />Kim I <br />