HomeMy WebLinkAbout25 - CC-11 - Attachment 3 - 5/5/2015ATTACHMENT B
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UP Purchase Requisition
Vendor ID:
(Leave Blank for Time
Stam
Purchase Order
Number
(Assigned by Purchasing)
Business Unit: CITY Date Requisitioned: 4/22/15
Department: Development Svs Division: HCD
Ship To Address: 77 Fair Drive, CM 92626
Contact Person: Silvia Kennerson Phone Number: x5023
Send Copy of P.O. to: E Contact Person and / or _
® Request is for Budgeted item(s)
❑ Request is for UNBUDGETED item(s)-(Memo Attached)
❑ Item(s) Pending Budget Amendment Request #
❑ Requesting Sole Source (Justification Form Attached
❑ Fixed Asset Tag Request
Item
No.
Qty Unit
Items (Give Full Description: Size, Catalog No. Etc.)
Unit Price
Estimated
Amount
1
1
Amendment One, First Renewal of Four, One Year Renewal Options
$ 85,000.00
Commencing 07/01/15 and Ending 06/30/16 to Provide CDBG/HOME
Professiona Services at $77.00/1-Iour, Not to Exceed $85,000.00/Year
ff additional lines are needed, please attach a second sheet
Const./Prof. Svs. Agmt. Completion Date: 06/30/16
Insurance Required: E Yes (Certificate attache ❑ No
Sales Tax (8.00%):
Include Shipping Fee:
Estimated Total Cost:
$ 85,000.00
Item #
Account
Fund
Dept./Org.
Program
Project
Amount
1
530201
207
11310
20427
$ 85,000.00
Comments:
Total$ 85,000.00
Email Address: mike@mlinaresinc.com
Suggested Vendor: Mike Linares, Inc.
Address: PO Box 3913
City, State, Zip Code: San Clemente, CA 92672
Phone: 714-608-7263 Fax:
Vendor's Contact Person: Mike Linares
Proper approvals are required before requisition can be processed.
Ordered By:
Depar} ant Dir for/Authorized Sj nature
Approved By:
Director of Finance/Purchasing Officer
Approved By:
rpt, Mananar (.hon roamrenl
PURCHASING DIVISION USE ONLY
Vendor ID:
Buyer:
Insurance valid thru
Ship To/Location:
I Due Date:
Standard Comments: ACC -ALL-ARR -BLA- CON-DCP- DIS - FCA-FCI- FIX - INS - IS - IST -ORG -QTR - REM -SUB -T&C
FINANCE DEPARTMENT USE ONLY
Available Appropriation: ❑ Yes ❑No
As of:
Confirmed By:
2385-20 MW REV 3/10
Rev FY 12113