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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/11/19 <br />�.............. �.�.�.......� �._._......._ Department <br />Nam <br />e Sean Ward/Terri Swift Streets <br />BPW Date 3/12/19 Phone Extension 7567 <br />INNM9IIX{a i .. ummi � r��,um�mmwm�anommm. uu r�u�omo�wvmi��n�mmuuuumwi �, ,,�mi�i <br />__IT_. et urcl. norIT_o Submittal to Boa. - <br />R . Pt rd <br />BPW Attorney ❑ Attorney Name Sandra penned <br />Dept. Attorney Attorney Name <br />Purchasing ❑ Michael Schutidt <br />_._. All Submissions <br />Checkthe A a ro �� gate Item "I' v- Required eor• <br />Professional Services Agreement Contract LJ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum F, Special Purchase, QPA <br />E] Bid Opening ❑ Bid Award El Req. to Advertise ❑ Title Sheet <br />Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PICA No. PICA <br />Other Chg. Order, N, o. E] Traffic Control E] Resolution <br />mm_ffiv ❑ Ease./Encroach <br />Reciuire,d Information <br />Company or Vendor Name <br />SealMaster <br />1._..Y.�sw 1 If Yes, Approved by Purchasing........e_. ^_................ a „ _........rw_ m ...............r� <br />� y <br />New Vendor <br />x No <br />MBE/WBE Contractor <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE E] No <br />Project Name <br />_mm2019 Street Cracksealin <br />Project Number <br />FundingSource <br />MVH......._��................._ ...................._�...�._....—..�_�....�.�......._�.w�.�,�........��..� <br />Account No. <br />202-0607-431 23-02 <br />Amount <br />TBD ill depend on the amount of material we purchase/$2,400 per <br />.._ .� ,...... er <br />kid <br />Terms of Contract <br />....................� , ............�... _...,,.................... ..�................ _.................. _�........... aaa. <br />Purpose/Description <br />for _the use gthe ..c... chine m ifthe. Streetm...D........e�p artmeni <br />purchases cracksealin material from SealMaster. <br />.. <br />For :"han Orders Ot���r <br />Amount of Increase $ <br />Decrease <br />Previous Amount $ _ <br />,...Increase....................—......m,�..........._ ..%... <br />.,�� ..o.... <br />Current Percent of Change: Decrease ( /o <br />New Amount $ <br />Increase %.... _ <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />