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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 10/19/2020 <br />Name Leslie Biek. PE Department PW <br />BPW Date 10/27/2020 Phone Extension <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />and Inclusion Officer Officer Name <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />I Check the Appropriate Item Tyne — Reauired for All Submissions <br />U Professional Services Agreement LJ Contract ❑ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum [] Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title <br />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 />❑ Other: Ease./Encroach <br />Reauired Information <br />Company or Vendor Name <br />I&M <br />❑ Yes❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />MBE/WBE Contractor <br />❑ WBE Completed E-Verify Form Attached El No <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />I&M requests an easement for a guy wire located on the north side of <br />Bertrand St 339 feet west of Meade St. The propeMLaddress is 309 <br />Olive St. <br />For Change Orders Only <br />Amount of ❑ <br />Increase $ <br />❑ <br />Decrease ($ ) <br />Previous Amount <br />$ <br />Increase % <br />Current Percent of Change: <br />Decrease <br />New Amount <br />$ <br />Increase % <br />Total Percent of Change: <br />Decrease ( %) <br />Time Extension Amount: <br />_ <br />New Completion Date: <br />