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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/04/2019 Department <br />Name Toy Villa Division/Bureau <br />Purchasing ❑ <br />Check the <br />Agreement Amendment <br />Professional Services <br />❑ Bid Opening <br />[� Quote Opening <br />Q Change Order No. <br />[l Ease/Encroach. <br />E, Other: <br />Company or Vendor Name <br />Public Works <br />Engineering <br />)ro rite Item Type — Required for All Submissions <br />❑ Contract Proposal <br />El Resolution <br />[:] Bid Award Req. to Advertise <br />El Quote Award <br />F� C/O & PCA No. ® PCA <br />F Traffic Control: <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of El Increase <br />Decrease <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Chanae: % <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tuired Information <br />Walsh & Kelly, Inc. <br />Addendum <br />❑ Title Sheet <br />❑ Yes ® No ❑ If Yes, Approved by <br />Purchasing <br />❑ MBE ❑ WBE <br />No ❑ Yes Name of Company <br />East Longfellow Avenue & North Riverside Drive Traffic Calming <br />118-113 <br />LRSA _M <br />.................. ...... ........... <br />_ <br />251.0608.431.42.96 <br />_.._....... ...... <br />Proiect Closeout <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion„ Non -Discrimination, Non -Debarment, E-Veri!y, Iran, etc. <br />abed For Chart .e Orders Only <br />_._ ................................................ <br />