R 2015-671 Planning - NC 811 Membership Agmt routing form.pdf, nc811 membership agreem

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Revised March 2012 ORANGE COUNTY—CONTRACT CONTROL SHEET Routing Order: (1) Department, (2) IT, (3) Risk Management, (4) Financial Services, (5) Attorney, (6) Manager, (7) Clerk This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for BOCC approval must be submitted through, and complete, the routing process prior to agenda review. Contracts for legal review should be completed through the legal review process prior to being routed for signature. Department Party/Vendor Name: North Carolina 811, Inc. Party/Vendor Contact Person: Lesley Brouillard Contact Phone: 336-855-5760 Party/Vendor Address: 2300 West Meadowview Rd, Ste 227 City Greensboro State: NC Zip: 27407 Department: Planning Amount: $100 Purpose: Membership in underground utility notification clearinghouse Budget Code(s): 51360120-807000 Vendor # New (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 10/1/2015 Approved by Board Yes No Agenda Date: Title of Contract: North Carolina 811, Inc. Membership Agreement If this is a Grant Agreement, pre-application has been approved by the Board of Commissioners Yes No . If submitted for bid were bids/RFPs received Yes No Bid/RFP number This contract has been reviewed and approved by the Department Director as to technical content: Department Director’s Signature: _________________________________________ Date: _____________ IT Director (Applicable only to hardware/software purchases or related services) This contract has been reviewed and approved by the Information 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 Required . Hold Contract pending receipt of Certificate of Insurance . With incorporation of Insurance provisions as shown, this contract is approved by the Risk Manager: Risk Manager’s Signature: ______________________________________________ Date: _____________ Financial Services This Contract is conditioned upon appropriation by the Board of Commissioners Yes No . A budget amendment is necessary before approval Yes No . If budget amendment is necessary, please attach to this form. This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Financial Services Director’s Signature: _____________________________________________ Date: ______________ County Attorney Approval by Board (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC consultant contract). Approval by Manager (Most other contracts $1,000 and above). Department Director approval only (Under $1,000). This contract has been reviewed and approved 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 Yes No . This contract has been reviewed and is for signature by the Chair Yes No . Manager’s Signature: _____________________________________________________ Date: _____________ Clerk to the Board Approved by BOCC on the ___ day of ____________, 20____. Submitted for Chair signature on the ___ day of ____________, 20____. Clerk’s Signature: ______________________________________________________ Date:______________ DocuSign Envelope ID: 61EC9A58-09AB-40C7-B61D-D35BA499F8D8