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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/14/2019 <br />�._.. _...._.._._.................................................................................. _ <br />Name Toy Villa Department Engineering <br />BPW Date 10/22/2019 Phone Extension 5920 <br />W <br />qIT IT ITITIT Submittal to Board <br />. mm Re used Prior to Subm� <br />BPW Attorney Attorney Name _._ ___._. <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />....... <br />Check the r)bronr <br />❑ Professional Services Agreement E] Contract <br />❑ Open Market Contract ❑ Amendment/Addendum <br />❑ Bid Opening Bid Award <br />Quote Opening ❑ Quote Award <br />Proposal Opening C/O & PCA No. <br />Chg. Order, No. ❑ Traffic Control <br />Other: <br />Required Informati <br />Company or Vendor Name SelgemConstruction Co., Inc. <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 />o All Submissions mm <br />Proposal <br />El Special Purchase, QPA <br />Req. to Advertise ❑ Title Shee <br />Reject Bids/Quotes <br />® PCA <br />E] Resolution <br />Ease./Encroach <br />U YesU If Yes, Approved by Purchasing <br />No <br />❑ MBE Completed E-Verify Form Attached Yes <br />❑ WBE No <br />Temoorary Traffic Calming Materials & Installation <br />_.................. <br />119-053 <br />LRSA Capital�666���..........._.....� <br />2 51mm. 0608.431.42.96 <br />Project Closeout <br />........ For "huge Orders Only <br />._ _ _ .. ...-....... <br />Amount of <br />Increase $ ._ <br />.....�.. -------------------------------------------------- <br />Decrease �$..................._.._._ <br />Previous Amount $ <br />Increase % <br />Current Percent of Change: Decrease % <br />New Amount $ <br />Increase % <br />Total Percent of Change: Decrease ( %) �mmmmm._._._. ITmmmmmmmmm <br />Time Extension Amount: <br />New Completion Date: <br />