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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 05/20/19 <br />Name Alicia Czarnecki Department Engineering <br />BPW Date 05/28/19 Phone Extension 5903 <br />JRcquired Prior to Submittal to Board <br />W Attorney ® Attorney Name <br />Dept. Attorney Attorney Name <br />Purchasing <br />Check the Appropriate Item Type - <br />Professional Services Agreement ❑ Contract <br />Open Market Contract <br />❑ Amendment/Addendum <br />[� <br />Bid Opening <br />® Bid Award <br />❑ Quote Opening <br />Quote Award <br />❑ <br />Proposal Opening <br />❑ C/O & PCA No. <br />Chg. Order, No. <br />❑ Traffic Control <br />Other: <br />All Submissions <br />" Proposal <br />Special Purchase, QPA <br />E] Req. to Advertise <br />0 Reject Bids/Quotes <br />❑ PCA <br />Resolution <br />0 Ease./Encroach <br />❑ Title Sheet <br />Required Information .� � ..... .......... <br />Company or Vendor Name <br />Premium Concrete Services, Inc. <br />-0",Y,e,s,Lj If Yes, Approved by Purchasing <br />New Vendor <br />Z No <br />MBE/WBE Contractor <br />0 WBE Completed E-Verify Form Attached Nos <br />Project Name <br />2019 Curb & Sidewalk Construction <br />Project Number <br />..................... ...._ <br />119-004 <br />Funding Source <br />MVH <br />Account No. <br />20__W.........._w�ww�.�..���� a...-.._._ ..........................__.. �................._.......� .� <br />2-0619-431.31-06 <br />Amount <br />$, Division... D.�����.����..................row <br />42124.00 ( 2) <br />Terms of Contract <br />.........:������-_-.....-_.___... <br />Unit Price Not to Exceed <br />�"uj)oasc,/Dcs I Lion <br />Award Divisions D2 of 2019 Curb and Sidewalk Program <br />For Clm nge Orders On <br />Amount of <br />increase $ <br />E] <br />Decrease ($ ) <br />Previous Amount <br />$ <br />_.�.._..................���.� _____........��._w ..... ...... ..... <br />Increase % <br />Current Percent of Change: <br />Decrease ( %) <br />New Amount <br />$ T <br />Increase % <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />_.... .............. _.._ ........ .. ........... <br />New Completion Date: <br />_ _....... ............... _........ ...... ... ....w..._..... <br />