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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/17/2019 <br />Name T�llaDepartment: Engineering <br />....... . ........................... . ... . . . ................ . ..... ____ ........... <br />BPW Date 12/19/2019 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />BPW Attorney El Attorney Name <br />Dept. Attorney <br />Purchasing <br />X7 <br />E] <br />Check the A <br />Attorney Name <br />Item TvDe — <br />H Professional Services Agreement H Contract <br />R <br />Open Market Contract <br />Amendment/Addendum <br />[J <br />Bid Opening <br />Bid Award <br />❑ Quote Opening <br />Quote Award <br />❑ <br />Proposal Opening <br />C/O & PCA No.2(Final) <br />Chg. Order, No. <br />Traffic Control <br />F� Other: <br />All Submissions <br />F1 Proposal <br />E] Special Purchase, QPA <br />E] Req. to Advertise ❑ Title Sheet <br />Reject Bids/Quotes <br />❑ PCA <br />FJ Resolution <br />Ease./Encroach <br />Company or Vendor Name <br />Pemberton -Davis Electric, Inc. <br />. . . . . . ...... . ........ . . ............ . ........ . . ....................... .. . . . ...... . . ..................................... . . . . . ............. .. . . . ................................................................ . .......................................................... <br />E] Yes E] If Yes, Approved by Purchasing <br />New Vendor <br />Z No <br />MBE M Yes <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />WBE ❑ No <br />Project Name <br />Mishawaka Avenue Traffic Signals at Fire Station #9 <br />Project Number <br />117-120A <br />... ... ........ .................... <br />Div. A — LRSA Traffic Signal Maintenance / Div. B — EMS Capital <br />Funding Source <br />Fund <br />Account No. <br />251.0608.431.36.67 / 287.0902.422.42.02 <br />.. . . . . . .......... - . . . . .. ........... ........................................................................................................................................ . . . . . . . . . . . . . . . . . . . . . . . ....... .. ....... .. ............ .. ............................... <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Project Closeout <br />For Chanize Orders OnI <br />Amountof 1:1 <br />Increase $ ­ ................... ......................... ............................ . ................... <br />Z <br />Decrease ($15,777.37) <br />Previous Amount <br />$ 187,923.94 <br />Increase % <br />Current Percent of Change: <br />Decrease _(�.40.0 <br />. .......... . . ......... <br />New Amount <br />$ 172,146.57 <br />......................... . . ................ . . . _.­­ ............ ..... . . . . . . . ................................. ..... ................................... ...................................... . . . . . .................... . ............... <br />Increase % <br />. ................... . ................................ . ................ . . ........... <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />. . ..... . ........— ------ . . .............. . ..... .... ...... . ........ . . . ............................................. <br />New Completion Date: <br />....... . . ...... . . . ............ - . . Completion . . ............................................................... <br />. ­­­­_.._._­ . ............................. ­­ ........... _._­_­_­­ . . ........ . . . ................. . . ..... . .... . ............................. . . . . . .................. . . ......... . . .. ......................... <br />