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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />10/01/2018 <br />Alicia Czarnecki/Kara Bovles <br />Purchasing <br />® Michael Schmidt <br />Department Engineering <br />❑ Agreement <br />[ I Contract L] Proposal Ll Addendum <br />® Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />n Other: <br />Company or Vendor Name Belfor USA Group, Inc. <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBEIWBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name Morris Theater Emergency Plaster Work <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />118-094 <br />Liability Insurance <br />226-0419-672.43-02 <br />$14,566.00 <br />Emergency work necessary to secure ceiling of Morris Performing <br />Arts Center and gain occupancV approval after plaster fell from rim <br />of main dome. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of ❑ 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 />❑ <br />Jeff Jarnecke <br />Kara <br />Dispersal After Approval <br />