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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 04/06/2020 <br />Name Alicia Czarnecki Department Engineering <br />BPW Date 04/14/2020 Phone Extension 5903 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer ❑ Officer Name <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type — Re uired or All Submissions <br />❑ <br />Professional Services Agreement ❑ Contract <br />Proposal <br />Open Market Contract Amendment/Addendum <br />Special Purchase, QPA <br />Bid Opening Bid Award <br />>< <br />Req. to Advertise ❑ Title Sheet <br />Quote Opening Quote Award <br />Reject Bids/Quotes <br />Proposal Opening C/O & PCA No. <br />PCA <br />Chg. Order, No. Traffic Control <br />Resolution <br />Other: <br />I <br />I Ease./Encroach <br />Required Information <br />Company or Vendor Name <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />❑ MBE <br />Yes <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />WBE <br />❑ No <br />Project Name <br />2020 Curb & <br />Sidewalk <br />Project Number <br />120-001 <br />Funding Source <br />MVH <br />Account No. <br />202-0619-431.31-06 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />For Change Orders Only <br />Amount of ❑ <br />❑ <br />Increase $ <br />($ 1 <br />Decrease <br />Previous Amount <br />$ <br />Increase % <br />Current Percent of Change: <br />Decrease ( %) <br />New Amount <br />$ <br />Increase % <br />Total Percent of Change: <br />Decrease ( %) <br />Time Extension Amount: <br />New Completion Date <br />