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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date ----- /20/20 <br />Department <br />Name —Carl Carl R. BticLianojit Fire C:Idof Fire...._ <br />BPW Date .« utic a 2020 Phone Extension 925 <br />WEEMWVN'IVIM "Jr 0 n H M I n I M I M In Iffiloyffiffiffm.. .. MN»9NW IW➢IYW6IMWW'NNV �z'mm���ummii yp uypK n{ryryWIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIWIWIWWWIIIdJd�!NiYN � WM,4M,wV'N'P,PH'�IVIAYIfW'�l'�IYdmIIIIIIWIWVIVIVIVIVIVIVIVIVIVIN1INWWIHfltiMMHHH? �H?±?.:3J23,4^i4 <br />— -- ....w ........—....,.—.,._..,,, ,�.. �. e�,,.�.,......»...,�..�...—..................------------------------- <br />�..,..,..... .�._.,mm......�.�. ....a.. �.�,.... ......... <br />Review and Lipp v l gqui d Prior to Submittal to Board <br />._ Diversity Compliance mmmmm �� � Officer Name �...._ W....�.w. <br />and Inclusion Officer <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney Attorney Name <br />Purchasing <br />❑IN <br />Check the A � tate Item Tie 1 <br />�❑ Professional Services Agreement [_1 Contract <br />❑ Open Market Contract EJ Amendment/Addendum <br />Bid Opening E] Bid Award <br />Quote Opening EJ Quote Award <br />Proposal Opening ❑ C/O & PICA No. <br />Chg. Order, No. ❑ Traffic Control <br />Other: <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 />LJ Yes L <br />❑] No <br />MBE <br />E] WBE <br />v All Submissions <br />LJ Proposal <br />Special Purchase, QPA <br />Req. to Advertise <br />F] Reject Bids/Quotes <br />PICA <br />Resolution <br />Ease./Encroach <br />❑ Title Sheel <br />........... -- <br />If Yes, Approved by Purchasing <br />Completed E-Verify Form Attached ❑ Yes <br />❑ No <br />Dis of Unfit Pro e�� IIa�lmets and Boots. -Retiree `al <br />l _ p�ta�n Nicholas <br />For Change wOrders � nl <br />Amount of <br />Increase $ <br />..m. <br />❑ <br />Decrease ($ ) <br />Previous Amount <br />$ <br />Increase <br />/o <br />Current Percent of Change: <br />Decrease <br />%� <br />New Amount <br />$ <br />......Increase ......................... <br />.......................................w <br />e.w� <br />% <br />Total Percent of Change: <br />Decrease <br />%) <br />Time Extension Amount: <br />.... . <br />New Completion Date: <br />— �.u............................................................�........��www.......... <br />.n......... -........................... <br />