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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/02/19 <br />Name Alicia Czarnecki Department En ►i.neerir�� <br />BPW Date 12/10/19 Phone Extension 5903 <br />mmomimimimmmnnmim <br />RNulr° d Prior to Submittal to Board <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney <br />Purchasing <br />Check the At <br />H Professional Services Agreement <br />❑ Open Market Contract <br />Bid Opening <br />Quote Opening <br />Proposal Opening <br />[� Chg. Order, No. <br />❑I Other: <br />Attorney Name <br />ate Item Type <br />Contract <br />F-1 Amendment/Addendum <br />Bid Award <br />E] Quote Award <br />C/O & PCA No. <br />❑ Traffic Control <br />eeeed Information <br />All Submissions <br />Proposal <br />❑j Special Purchase, QPA <br />R Req. to Advertise <br />F Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Company or Vendor Name <br />TBD <br />Yes❑ If Yes, Approved by Purchasing <br />New Vendor <br />No <br />❑ <br />MBE/WBE Contractor <br />WBE Completed E-Verify Form Attached <br />No <br />Project Name <br />Light Up South Bend—,Lihted Decorative Bollard Replacements <br />Project Number <br />119-005B <br />Funding Source <br />........ ......�w.......w ��..�....-........��.�.....�.............�. <br />COIT <br />Account No. <br />....................................... <br />404-0602-431.22-40...... _m_ _�...._ <br />Amount <br />................._...................................._.. ................. <br />TB D <br />Terms of Contract <br />__.. <br />Purpose/Description <br />........................................ .____.. .......................... <br />Amount of <br />Increase $........ ..... .._.. <br />�....w. <br />Decrease ($ ) <br />Previous Amount <br />$ <br />..Increase ������__���__���.�_�...._��... <br />�..�.�........................................................_�........_...... . <br />Current Percent of Change: <br />g <br />Decrease %) <br />..._ ____.. ._....................w <br />New Amount <br />$ <br />Increase %.���_�..� �..��� .......�w <br />Total Percent of Change: <br />._ _. _...... ....................... <br />Decrease ( %) <br />Time Extension Amount: <br />New Completion Date: <br />