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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 7/11/2019 <br />Department <br />Name Sue Ellen Doudrick Engineering Division <br />I'llBPW Date 7/23/2019 Phone Extension 5922 <br />��wm ., r �s�a�a��sv+,��.ma9r ,mv,»tr�;n�rw� ,_. �un�u�umriu�u,�w.....;m�aa ��imrrr���ir.�v .:�.:....-,--.u�aw.Earw.;r�✓n�u�uwuuuwmwwwwwwuwwwrw�unwww!�.o,,. � mar <br />Board Required Prior to Submittal to B.. _______.�,,, <br />BPW Attorney ® Attorney Name Clara McDaniels <br />Dept. Attorney Attorney Name <br />. . . . . ........................... _................ m- <br />Purchasing ❑ <br />Check the A <br />ate Item Type - Regnired ,Far All Submissions <br />Professional Services Agreement ❑ Contract <br />0 Open Market Contract <br />❑ Amendment/Addendum <br />Bid Opening <br />❑ Bid Award <br />(� Quote Opening <br />❑ Quote Award <br />Proposal Opening <br />❑ C/O & PCA No. <br />Chg. Order, No. <br />❑ Traffic Control <br />® Other: Emergency Sewer <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 />Required Informatfon <br />f Proposal <br />Special Purchase, QPA <br />❑ Req. to Advertise <br />Reject Bids/Quotes <br />PCA <br />Resolution <br />Ease./Encroach <br />Sample Street Emergency Sewer Repair <br />119-060 <br />Emer e... _______________ <br />--P <br />ocess - see memo <br />Time and Materials <br />See attached memo. <br />❑ Title Sheet <br />For Chang'e Orders Only <br />Amount of ❑ <br />Increase $ <br />❑ <br />Decrease ($ ) <br />Previous Amount <br />�.........�. <br />$ <br />......... ........... - <br />Increase <br />% <br />Current Percent of Change: <br />g <br />Decrease <br />%) <br />New Amount <br />$ _ ......... ..... <br />_ ..... .......... <br />.....----------- - <br />Increase <br />---- --........._..��...............................................................................................-- <br />% <br />Total Percent of Change: <br />Decrease^ <br />%) <br />Time Extension Amount: <br />New Completion Date: <br />....................... .. ...... -- ---- <br />