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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/13/2019 <br />�.�............._.......... <br />Department Public <br />Namemmm .............. ww Becca Plantz <br />Works <br />BPW Date 12/19/19 <br />Phone Extension 5998 <br />Required Prior to Submittal to Board <br />BPW Attorney <br />Attorney NamemmmmWW mm WWm <br />�................... <br />Clara McDaniels <br />Dept. Attorney <br />Attorney Name <br />Purchasing1:1 <br />......_............................................... ... <br />...... <br />�............... Check the A t`c ruts Item "I� p - <br />Cl � irre r All Submissions <br />Professional Services Agreement EJ Contract <br />...... <br />1:1 Proposal <br />Open Market Contract <br />❑ Amendment/Addendum E] Special Purchase, QPA <br />❑ Bid Opening <br />® Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />Quote Award <br />❑ Reject Bids/Quotes <br />E] Proposal Opening <br />C/O & PCA No. <br />PCA <br />F Chg. Order, No. <br />❑ Traffic Control <br />Resolution <br />Other: <br />Ease./Encroach <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 />HRP C <br />❑ Yes <br />No <br />� e d Information <br />Inc. <br />If Yes, Approved by Purchasing <br />MBE Completed E-Verify Form Attached ❑ Nos <br />WBE <br />Privet Lane Culvert wRealaccnient Project <br />. ........._............ <br />I I8-013B <br />LRSA Major Projects ......................................... w_ <br />251-0608-431.42-96 _... _ . <br />Unit Price �_�_........._... <br />µ Removing and r l it f imlin�g existin culvert on Privet Lane. mm^� <br />For Change <br />Orders Onl....._...... _. ... w <br />Amount of <br />Increase $ <br />������, ,,,�............_.........._.- ... <br />Decrease ($ <br />) <br />Previous Amount <br />$ <br />................................ <br />Increase <br />� �......... <br />% <br />Current Percent of Change: <br />Decrease <br />( /o) <br />New Amount <br />$ <br />............ <br />...._....._._...... ...._.-_......... ww_........._... <br />Increase <br />% <br />Total Percent of Change: <br />Decrease <br />( %) <br />Time Extension Amount: <br />New Completion Date: <br />