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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2/19/19 Department Public Works <br />......................... ....... <br />Name Kyle Silveus Division/Bureau Engineering <br />Check the Appropriate Item Type — Re wired for All Submissions <br />❑ <br />Agreement <br />❑ Contract Proposal El Addendum <br />Professional Services <br />❑ Resolution <br />[� <br />Bid Opening <br />0 Bid Award ® Req. to Advertise ® Title Sheet <br />�) <br />Quote Opening <br />El Quote Award <br />❑ <br />Change Order No. <br />C/O & PCA No. ❑ PCA <br />Ease/Encroach. <br />Traffic Control: <br />M Other: <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 />TBD <br />...... ...... .... <br />❑❑ Yes 1 No If Yes, � <br />_..... <br />MBE E] WBE <br />No ❑ Yes Name of C...-_..... <br />o <br />Main and Jefferson Earthwork <br />119-022 <br />.............. <br />RWDA TIF <br />324-1050-460.42-01 <br />TBD <br />by Purchasi <br />Terms of Contract TBD <br />..................... ............ <br />Purpose/Description Base Bid <br />............. _........... <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />p re For Chan a Orders gLn <br />Amount of Increase $ <br />�] Decrease $ <br />Previous Amount _ ._.. <br />Current Percent of Change: <br />New Amount <br />Total Percent of Chanae: <br />Discersal After <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />El <br />