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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/30/2020 <br />Department <br />Name Sue Ellen Doudrick Engineering Division <br />BPW Date 4/14/2020 Phone Extension 5922 <br /> <br />Required Prior to Submittal to Board <br />BPW Attorney Attorney Name <br />Dept. Attorney Attorney Name <br /> <br />Purchasing <br />Check the Appropriate Item Type Required for All Submissions <br /> Professional Services Agreement Contract Proposal <br /> Open Market Contract Amendment/Addendum Special Purchase, QPA <br /> Bid Opening Bid Award Req. to Advertise Title Sheet <br /> Quote Opening Quote Award Reject Bids/Quotes <br /> Proposal Opening C/O & PCA No. PCA <br /> Chg. Order, No. Traffic Control Resolution <br /> Other: Emergency CSO Ease./Encroach <br />Repair <br />Required Information <br />Company or Vendor Name Selge Construction <br /> Yes If Yes, Approved by Purchasing <br />New Vendor <br /> No <br /> MBE Yes <br />MBE/WBE Contractor Completed E-Verify Form Attached <br /> WBE No <br />Project Name CSO 018 and Backwater Gate Emergency Repair <br />Project Number 120-017 <br />Funding Source Emergency PO <br />th ϔ ЋЎЏАЏЎ <br />Account No. <br />Amount $24,430 <br />Terms of Contract Time and Materials <br />See attached memo._____________________________________________ <br />Purpose/Description <br />For Change Orders Only <br />$ <br /> Increase <br />Amount of <br /> Decrease ($ ) <br />Previous Amount $ <br /> % <br />Increase <br />Decrease ( %) <br />Current Percent of Change: <br /> <br />New Amount $ <br /> % <br />Increase <br />Decrease ( %) <br />Total Percent of Change: <br /> <br />Time Extension Amount: <br />New Completion Date: <br /> <br />