HomeMy WebLinkAboutR 2014-336 ES - New Hope Fire Dept. for User Agreement for EMS Substation ORANGE COUNTY-CONTRACT CONTROL SHEET
Routing Order: (1)Department,(2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7) ( It.•rk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. 1101c 'Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval ( omtracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for lega l i ",i c\� should
be completed through the legal review process prior to being routed for signature.
Department
Party/Vendor Name: New Hope Fire Department Party/Vendor Contact Person: Mike Tapp Contact Phone: 919 493-1001
Party/Vendor Address:4700 NC Highway 86 City Chapel Hill State:NC Zip:27514 Department:Emergency Services ,lniouitt:
$6000.00 Purpose:User Agreement for Emergency Medical Services Substation Budget Code(s): 10757520-630000 Vern 1w t44
(N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type: (Check one)New❑ Renewal® � n cndment
❑ Effective Date Approved by Board Yes❑No❑ Agenda Date: Title of Contract: Orange County_- 'ceN� Hone
Fire Department User Agreement for Emergency Medical Services Substation
If this is a Grant Agreement,pre-application has been approved b e Board of Commissioners Yes❑No❑. If submit[,.I r'k,r bid were
bids/RFPs received Yes❑Non Bid/RFP number Thi o tract has been reviewed and approved by the Department I)hector as to
technical content:
Department Director's Signature: Date: 7
IT Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the I n t 0nnation
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
Risk Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance ReguircJ ❑. Hold
Contract pending receipt of Certificate of Insurance E]. With incorporation of Insurance provisions as showu. thk a.1,.i;;,a roved
by the Risk Manager:
QLD
Risk Manager's Signature: e� ... � Date: JUL L' 4L��
1714L-21 717 �.n,.
Financial Services
This Contract is conditioneppropriation by the Board of Commissioners Yes❑NoB� A b t �m=dinent i� n ess
before approval Yes❑Nov[17�. If budget amendment is necessary,please attach to this form. This instrument has been prc_ <iticFfe m e
manner required by the Local Government Budget and Fiscal Control A
Financial Services Director's Signature: 34'66--ik �' h''r� Date:
County Attorney
Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction. rr any BOCC
consultant contract). Approval .Manager Most other contracts$1,000 and above). Department Director approval I ❑ (Under
$1,000). This contract has been e iewed an proved by the Attorney as to legal form and sufficiency:
Attorney's Signature Date:
County Manager
This contract has been reviewed and is approved by the County Manager YesENo❑.
This contract has been reviewed and j�for signature by the Chair Yes❑No❑.
Manager's Signature: ' Date:
r �
Clerk to the Board
Approved by BOCC on the day of 120 Submitted for Chair signature on the day of . 20
Clerk's Signature: Date:
Revised March 2012