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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 04/21/2020 <br />Name Toy Villa Department Engineering <br />BPW Date 04/28/2020 Phone Extension 5920 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />❑ <br />Attorney Name <br />Dept. Attorney <br />❑ <br />Attorney Name <br />Purchasing <br />❑ <br />Check the Appropriate <br />Item Type — Re uired or All Submissions <br />❑ Professional Services Agreement <br />❑ Contract <br />❑ Proposal <br />❑ Open Market Contract <br />❑ Amendment/Addendum <br />❑ Special Purchase, QPA <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Reject Bids/Quotes <br />❑ Proposal Opening <br />® C/O & PCA No. 1 final <br />❑ PCA <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />❑ Resolution <br />❑ Other: <br />❑ Ease./Encroach <br />Required Information <br />Company or Vendor Name <br />Peerless Midwest, Inc. <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />MBE Yes <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />❑ ❑ No <br />Project Name <br />Edison Well 43A Rehabilitation <br />Project Number <br />119-097 <br />Funding Source <br />Water Works — Source of Supply and Other Professional Services <br />Account No. <br />620.0640.602.31.06 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Proj ect <br />Closeout <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />® Decrease ($ 4,550.00) <br />Previous Amount $ 66,900.00 <br />Increase <br />Current Percent of Change: <br />Decrease <br />New Amount <br />$ 62,350.00 <br />Increase <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />New Combletion Date: <br />7.30% <br />7.30%) <br />