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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December ,19,2019 <br />Name Dan Buckenmever Department DCI <br />BPW Date December 19 2019 Phone Extension 5823 <br />A �Iwyifim� N=�IMXM <br />Re i i ir ed Prior to Submittal to Board <br />............ <br />BPW Attorney F-1 Attorney Name <br />Dept. Attorney Attorney Name Sandra Kennedy <br />Purchasing <br />Check the Appropriate Item Type - <br />El Professional Services Agreement Z Contract <br />F-1 <br />Open Market Contract F-1 Amendment/Addendum <br />F] <br />Bid Opening n Bid Award <br />E] <br />Quote Opening El Quote Award <br />E] <br />Proposal Opening C/O & PCA No. <br />E] <br />Chg. Order, No. Traffic Control <br />F] Other: <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 />uircd Information <br />All Submissions <br />E] Proposal <br />E] Special Purchase, QPA <br />E] Req. to Advertise <br />E] Reject Bids/Quotes <br />F] PCA <br />E] Resolution <br />Ease./Encroach <br />...................................... <br />Ziker Sample Street, LLC (d.b.a. "Vested Interest' <br />Yes ❑ If Yes, Approved by Purchasing <br />No <br />MBE Completed E-Verify Form Attached <br />F-JWBE <br />Small Business Assistance <br />18J022,19JO20 <br />. .............. <br />COIT <br />404.1001.460.39-30 <br />$5,150,00 <br />Provide Small Business Assistance <br />0 Title Sheet <br />El Yes <br />F-1 No <br />............. . . . . For Change Orders Only........._ . .......... . . . ....... . <br />F-1 Increase <br />Amount of . ......... <br />F] Decrease <br />Previous Amount <br />Increase % <br />Current Percent of Change: Decrease . ... .. .. <br />New Amount <br />Increase % <br />........... <br />Total Percent of Change: Decrease %) <br />Time Extension Amount: <br />..................................... <br />New Completion Date: <br />