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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/11 /19 <br />Name Alicia Czarnecki <br />Department Public Works <br />Division/Bureau Engineering <br />BPW Date 10/22/19 Phone Extension 5998 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name: Clara McDaniels <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />g Check the <br />Am A reement endment <br />Professional Services <br />❑ Bid Opening <br />El Quote Opening <br />Change Order No. <br />Ease/Encroach. <br />F1 Other: <br />Fate Item Type — <br />Contract <br />Resolution <br />0 Bid Award <br />El Quote Award <br />❑ C/O &PCANo. <br />_ <br />❑ Traffic Control: <br />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />uired Information <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Company or Vendor Name <br />American Structureoint Inc <br />New Vendor <br />�� <br />Yes <br />No ��. <br />_ ..... [� If Yes, A roved b� Purchasing <br />MBE/WBE Contractor <br />E] <br />�._ _ ..�... <br />MBE El WBE <br />MBE/V1/BE Contractor Requested <br />m ......- <br />�] <br />.... <br />� �... �. <br />�,,,_......_.... .._.... <br />No ❑] Yes Name of Com an <br />.. .,, .. ����... ._......... <br />Protect Name <br />m,,, mm.m <br />Traffic Signal System Inventor r ....... ._. <br />Project Number <br />119-001 <br />FundingSource <br />�_. <br />LRSA Traffic Signal Maintenance <br />..... �m. Ce ....w.......... <br />Account No. <br />251-0608-431.36.67 <br />Amount <br />Amendment 300.00 New Contract Amount $, m,,,,,......._. <br />nt 1: $34, 127,860.00 <br />Terms of Contract <br />Hourly Not to Exceed <br />Purpose/Description <br />.._ ..... �.w�___ m............ <br />Amendment 1 for the additional services of increasing the <br />number of intersections for field inventory, system timing review, <br />and model development. <br />Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />�..: _ .. a !red For Cgn e'Orders Ppl� .._ ._.:.. <br />Amount of ❑ <br />E] <br />Increase <br />Decrease <br />_.''....... <br />$..... <br />$ <br />Previous Amount $ <br />Current Percent of Change:._.......�......�........%...........___ <br />New Amount $ <br />Total Percent of Change: % <br />Copy Original ._�.... .. <br />C' grsal After A roval <br />❑ ❑ <br />