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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/10/2019 <br />Department <br />Name Toy Villa .�✓ Engineering <br />BPW Date Z . t 9 Phone Extension 5920 <br />Required Prior to Submittal to Board <br />BPW Attorney �] Attorney Name <br />Dept. Attorney Attorney Name <br />..................... <br />Purchasing _.............. <br />❑ Professional Services Agreement r-1 Contract <br />n Open Market Contract <br />n Amendment/Addendum <br />E, Bid Opening <br />Bid Award <br />Quote Opening <br />❑] Quote Award <br />❑ Proposal Opening <br />❑ C/O & PCA No. <br />Chg. Order, No. <br />❑ Traffic Control <br />Other: <br />Required Information <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 />All Submissions <br />L j Proposal <br />Special Purchase, QPA <br />❑ Req. to Advertise <br />❑ Reject Bids/Quotes <br />® PCA <br />❑ Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />M & V Pro Services, Inc. <br />E] Yes], If Yes, Approved by Purchasing <br />n No <br />❑ MBE Completed E-Verify Form Attached ❑ Yes <br />❑ WBE ❑ No <br />Palais Royale Interior Painting <br />119-055R <br />Historic Preservation <br />450 0405-453.36-01 <br />$ 34,160.00 <br />Project Closeout <br />For Charge Orders Only <br />...�... ....__.. <br />Amount of Increase $ 0 <br />Decrease ($ 0 <br />........ ...... <br />Previous Amount $ <br />___________________w_ww .._..... <br />Increase 0% <br />.........._..... _............ <br />Current Percent of Change: Decrease (0%) <br />New Amount $ <br />......._........ <br />0�.......................... �..........._ <br />/o Increase 0 <br />Total Percent of Changer Decrease (0%. <br />Time Extension Amount: <br />........................�.... . <br />New Completion Date: <br />