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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 06/17/19 <br />Name Alicia Czarnecki Department Engineering <br />BPW Date 06/25/19 Phone Extension 5903 <br />XAkKI/�Hrvp'� ii. Y Mltl�.!W.VIIWIIWIIVIVIVMVW�'+ ww<x q,y�py, Il�'iIANNiNnNMigN �� C�Y,R�VIONANI�IMWI��i �nIWNM�NM'9!� � � IIIIIONNiY�Pf�,'Yiz�t9'. <br />Required Prior to Submittal to Board <br />... ......._... ..... _.. <br />BPW Attorney ❑l Attorney Name <br />Dept. Attorney El Attorney Name <br />Purchasing F <br />Check the A <br />LJ Professional Services Agreement <br />Open Market Contract <br />F-j Bid Opening <br />❑! Quote Opening <br />(❑ Proposal Opening <br />El Chg. Order, No. <br />E] Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />ate Item yp <br />Contract <br />❑ Amendment/Addendum <br />❑ Bid Award <br />❑ Quote Award <br />❑] C/O & PCA No. <br />❑ Traffic Control <br />uired Information <br />r fb�All Submissions <br />L J Proposal <br />0 Special Purchase, QPA <br />Req. to Advertise <br />® Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Yes Yes, A roved by P ha <br />—.., <br />If <br />pp urchsing <br />No <br />MBE Completed E-Verify Form Attached El Yes <br />❑ WBE ❑ No <br />Muessel Grove Public Restroom <br />118-099 <br />PA Capital <br />416.0404.453,36.01 <br />Public Restroom renovation at Muessel Grove Park to restore functionalit3 <br />and meet all aplio lal.e state and federal code re UimMerncnts. <br />E---- — <br />_._. u_� <br />ForwCh� Orders Onlm <br />Amount of El <br />Increase $ <br />❑ <br />Decrease ($ ) <br />Previous Amount <br />$ <br />Increase <br />Current Percent of Change: <br />Decrease <br />%) <br />New Amount <br />$ <br />.............................................................w <br />Increase <br />% <br />Total Percent of Change: <br />Decrease ( <br />_.�. <br />o ) <br />/o <br />Time Extension Amount; <br />New Completion Date: <br />