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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 03/03/2020 <br />Name Zach Hurst Department DPW <br />BPW Date 03/10/2020 Phone Extension 3057 <br />Review and /�,1�•oval R.eto��re� Prior to Submittal to Board <br />Diversity Compliance ❑ Officer Name <br />and Inclusion Officer <br />BPW Attorney]' Attorney Name <br />Dept. Attorney Attorney Name <br />Purchasing <br />0 <br />Check the Appropriate Item l'ype — <br />Professional Services Agreement ❑ Contract <br />E] <br />Open Market Contract <br />❑ <br />Amendment/Addendum <br />E] <br />Bid Opening <br />Bid Award <br />n <br />Quote Opening <br />Quote Award <br />EI <br />Proposal Opening <br />C/O & PCA No. <br />E] <br />Chg. Order, No. <br />❑ <br />Traffic Control <br />® Other: Storm Sewer Access <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 />LJ Special Purchase, QPA <br />E] Req. to Advertise <br />E] Reject Bids/Quotes <br />PCA <br />[� Resolution <br />❑ Ease./Encroach <br />❑ Title Sheel <br />Bald Mountain LLC <br />_.................... ... <br />�] Yesif Yes, Approved by Purchasing <br />No <br />MBE Completed E-Verify Form Attached ❑ No <br />WBE <br />201 S Main — Barnes and Thornburg Building <br />N/A <br />N/A <br />N/A <br />Bonn sewer access a geement allowing emergencycraergency overflow ipe into City <br />storm sewer system. <br />For Chan e Orders 011 <br />Amount of Increase $ <br />Decrease ($ ) <br />Previous Amount $ �ITITITITITITITITmmITITmmmITIT� <br />Increase % <br />Current Percent of Change: Decrease ( %) <br />New Amount $ <br />Increase % <br />Total Percent of Change: Decrease _ ( %) <br />Time Extension Amount: <br />New Completion Date: <br />