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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 07/07/2020 <br />Name Alicia Czarnecki Department Engineering <br />BPW Date 07/14/2020 Phone Extension 5903 <br />Required Prior to Submittal to Board <br />BPW Attorney ® Attorney Name <br />Dept. Attorney ® Attorney Name <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 />n Other: n Ease./Encroach <br />Company or Vendor Name American <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 />Inc. <br />U Yes U If Yes, Approved by Purchasing <br />® No <br />❑ WBE Completed E-Verify Form Attached ❑ Yes <br />No <br />Pinhook Water Treatment Plant Improvements <br />119-003 <br />Water Capital <br />No Change in Contract Amount (Original Agreement: $179,400.00) <br />NTE <br />_ Project delivery method is changing to Guaranteed Savings Contract - this <br />revised document reflects the design contract changes associated. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Increase <br />Decrease <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />