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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 1/22/2020 <br />Department <br />Name Toy Villa _ En ineerin <br />BPW Date 2/11/2020 Phone Extension 5920 <br />.. _.......W__W <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer <br />BPW AttorneyOfficer Name <br />_......._� .. ..... ..............�� _�M .... <br />❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Atmron iate Item Twe — Reati <br />Professional Services Agreement F] Contract <br />Open Market Contract Amendment/Addendum <br />Bid Opening Bid Award <br />Quote Opening El Quote Award <br />Proposal Opening ❑ C/O & PCA Nol <br />Chg. Order, No. Traffic Control <br />El 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 />Information <br />All Submissions <br />(� Proposal <br />Special Purchase, QPA <br />❑ Req. to Advertise <br />❑], Reject Bids/Quotes <br />® PCA <br />❑ Resolution <br />0 Ease./Encroach <br />Ziolkowski Construction, Inc. <br />Yes If Yes, Approved by Purchasing <br />® No <br />[� MBE Completed E-Verify Form Attached <br />WBE <br />315 & 319 W. Jefferson Exterior Renovations — Division B <br />1..19-064,mmmDiv. B.... <br />.......�................ ........ ......... _.....-._..........._.....................__. ....... <br />RWDAwTIF...................................................................... .. <br />324-1050-460-42.02 <br />......................................................................._............._............................. <br />$64,372.00 <br />Project <br />Closeout <br />❑ Title Sheet <br />For Change Orders OnlyITmmmpp <br />Amount of Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Increase <br />% <br />.......... <br />Current Percent of Change: <br />Decrease <br />New Amount <br />$ _ _... <br />_Increase ........................ <br />_.__.......�.._.._....% <br />.............................. <br />Total Percent of Change: <br />Decrease <br />%° <br />Time Extension Amount;. <br />_..............._...��������_._................��._._._.....��........_.....��������...... <br />NewCompletion Date: <br />❑ Yes <br />❑ No <br />