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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date November 18, 2019 <br />Name Roger T. N w ot <br />a rot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />BPW Date November 26, 2019 Phone Extension 5932 <br />........_ _______________ <br />Required Prior to Submittal to; Board <br />Legal ❑ Attorney Name: <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 />m Check the <br />H Agreement <br />EJ Professional Services <br />F1 Bid Opening <br />El Quote Opening <br />❑ Change Order No. <br />F-1 Ease/Encroach. <br />�] Other: <br />Company or Vendor Name <br />ipropriate Item Type - <br />[� Contract <br />❑ Resolution <br />® Bid Award <br />El Quote Award <br />n C/O & PCA No. <br />E] 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 />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />uired Information <br />Martell Electric, LLC <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />El Yes N No El If Yes, Approved by <br />Purchasing <br />....._.. ......... <br />❑ No ❑ Yes Name of Company <br />Ewin�venue andFellowsStreet Traffic Signal Replacementm ___..... <br />118-097 <br />LRSA Traffic Signal Maintenance_ <br />251.0608.431.36-67_ m._._ ._ <br />$194,604.50 <br />Unit Prices <br />H Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />WW.._. • ...................... .... _.. <br />. __.._.__.____..............---- ____�._��______..__ Required For ChanmgewWOrders Only <br />Amount of El Increase $ w <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Dispersal After Awroval <br />Copy <br />Original <br />F-1 <br />El <br />El <br />