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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 4, 2019 <br />Name Roger Nawrot <br />Purchasing ❑ <br />Check the , <br />Agreement <br />El Professional Services <br />F Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />❑ Other: Amendment No. 1 <br />Department Public Works <br />Division/Bureau Engineering <br />iropriate Item Type — Req� <br />_._.. <br />❑ Contract <br />Ej Resolution <br />0 Bid Award <br />F� Quote Award <br />C/O & PCA No.. <br />❑' Traffic Control: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />for All Submissions <br />Proposal <br />Req. to Advertise <br />❑ PCA <br />Required Information <br />Christopher B. Burke En inee <br />El Yes No <br />❑ MBE 0 WBE <br />El No ❑ Yes Nam <br />e ofC_ <br />Boland Trail <br />113-047 <br />$ 20,000.00 <br />.. .. <br />Not to Exceed <br />Addendum <br />❑ Title Sheet <br />WLLC <br />If Yes, Approved by Purchasi <br />Purpose/Description Total Contract Amount $148„500 <br />.......... <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change �..__ g Orders Ooly <br />Amount of ❑ Increase $ <br />El Decrease $ ............... ... ..... ........ __....._. <br />Previous Amount $ <br />. ........................ ......... .. ........ -_._ .___ <br />Current Percent of Change: % <br />New Amount $ <br />....... _ .. ......................................... _...._ <br />Charx�e _� .......... %...__._. _ — <br />[__........ Dispersal AfterA�proval <br />Total Percent of ......._. ___.�..._ <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />0 0 <br />