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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name Lauren'rra Department Utilities <br />BPW Date 5/12/20 Phone Extension 5852 <br />11WIDIWI N, f0 <br />...M ................................... .mm............ <br />Review and Approval lle iiircd Prior to Submittal to Board <br />_. _ .. <br />Diversity Compliance ❑ Officer Name <br />and Inclusion Officer <br />BPW Attorney Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing <br />Check the Appropriate Item Type — <br />LJ Professional Services Agreement Contract <br />❑ Open Market Contract <br />Amendment/Addendum <br />❑ Bid Opening <br />Bid Award <br />Quote Opening <br />Quote Award <br />El Proposal Opening <br />❑ C/O & PCA No. <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />® Other: Imagineerin� <br />Modified Permit <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 />L JI Special Purchase, QPA <br />EJ Req. to Advertise <br />Reject Bids/Quotes <br />[] PCA <br />E] Resolution <br />[:] Ease./Encroach <br />U YesU If Yes, Approved by Purchasing <br />n No <br />❑ Title Sheei <br />MBECompleted E-Verify Form Attached 0 Nos <br />For Change Orders Opt <br />Amount of Increase $ ............... <br />Decrease$ ) <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />New Completion Date: <br />Increase <br />Decrease <br />.. W /o <br />Increase <br />% <br />Decrease <br />( % <br />