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Date 10/ 14/2020 <br />Name Toy Villa Department Engineering <br />BPW Date 10/27/2020 Phone Extension 5920 <br />Review and Approval Required Prior to Submittal to Board <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 Tvne — Reauired for All Submissions <br />U Professional Services Agreement U Contract U Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ® C/O & PCA No. I (Final) ❑ PCA <br />❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution <br />❑ Other: ❑ Ease./Encroach <br />Reauired Information <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 />Premium Concrete Services, Inc. <br />❑ Title <br />Sheet <br />U Yes U If Yes, Approved by Purchasing <br />® No <br />❑ MBE Completed E-Verify Form Attached ❑ Yes <br />❑ WBE ❑ No <br />Walnut Grove and North Riverside Drive Traffic Calming <br />119-071 <br />LRSA <br />251.0608.431.42.96 <br />$81,336.00 <br />Project Closeout <br />For Change Orders Only <br />Amount of ® Increase $ 3,836.00 <br />❑ Decrease ($ ) <br />Previous Amount $ 77,500.00 <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />Increase 4.95% <br />Decrease ( %) <br />$ 81,336.00 <br />Increase 4.95% <br />Decrease ( %) <br />New Completion Date: <br />