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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 9/29/2020 <br />Name Leslie Biek Department Engineering <br />BPW Date 10/13/2020 Phone Extension <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ® Officer Name Larry King <br />and Inclusion Officer <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney <br />Attorney Name <br />Clara McDaniels <br />Purchasing ® <br />Ron O'Connor <br />Check the Appropriate <br />Item Type — Re uired <br />or All Submissions <br />® Professional Services Agreement ❑ 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. <br />❑ PCA <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />❑ Resolution <br />n Other: <br />n Ease./Encroach <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 />Abonmarche <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />® No <br />E] MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Sample and Mayflower Intersection Improvement <br />120-052 <br />$41,000 <br />80 calendar days from NTP <br />PSA for the Traffic Analysis and Design of the Sample and Mayflower <br />intersection to improve the safety of the intersection <br />For Change Orders Only <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 />Increase % <br />Decrease ( %) <br />