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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 07/1.5/1.9 <br />Name Alicia Czarnecki Department E gincerin .;g <br />BPW Date 07/23/19 Phone Extension 5903 <br />r��rttuai�r���.m .m �r,n.. ,. ,. --,,.� �✓^.w.�.��r.�.rr�amtwe, ,a�+a�urnu�m ... ,a�rr ,.�.n����:...� <br />lliNNOU&VPIJPEW'.i!' III�N�6M4PItAIVMp@� ¢��mv�zmmi:; <br />Required Prior to Submittal to Board <br />BPW Attorney Attorney Name <br />Dept. Attorney '` Attorney Name <br />� �...—.......-....... ............. ........... .................................................................................................................................._............... <br />Purchasing <br />Check the Appropriate Item Type - f equir ed lbr All Submissions <br />[_] Professional Services Agreement ❑ Contract <br />E <br />Open Market Contract ❑ Amendment/Addendum <br />Bid Opening ❑ Bid Award <br />Quote Opening ❑ Quote Award <br />[: <br />Proposal Opening C/O & PCA No. <br />❑' <br />Chg. Order, No. �]', Traffic Control <br />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 />ired Information <br />H Proposal <br />0 Special Purchase, QPA <br />❑ Req. to Advertise <br />E] Reject Bids/Quotes <br />PCA <br />Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Selge Construction _ <br />❑] Yes ❑ If Yes Approved by Purchasing <br />No <br />0 MBE Completed E-Verify Form Attached ❑ Yes <br />[:] WBE ❑ No <br />Temporary Traffic Calming Materials & Installation <br />_ w.... <br />119-053 <br />LRSA Capital <br />...... <br />- ._....�..............w__..,..,.,.,...........m. <br />251-0608-431.42-96 <br />$67,350.00 <br />Procure and install rubber temporary traffic calming materials for local <br />roads in various locations with the City of South Bend. <br />For Chan e Orders_Onl. <br />Amount of <br />Increase $ <br />] <br />Decrease ($ ) <br />Previous Amount <br />$ <br />.Increase <br />__ ....................................%....... <br />Current Percent of Change- <br />Decrease <br />%) <br />New Amount <br />$ <br />Increase ............................_._........._ <br />Total Percent of Change: <br />Decrease <br />( %) <br />Time Extension Amount: <br />New Completion Date: <br />C --.r---- ........... _........ <br />