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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 01/20/2021 <br />Name Zach Hurst Department DPW <br />BPW Date 01/26/2021 Phone Extension 3057 <br /> <br />Review and Approval Required Prior to Submittal to Board Diversity Compliance <br />and Inclusion Officer Officer Name BPW Attorney Attorney Name <br />Dept. Attorney Attorney Name <br /> <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 /> Other: Long Term <br />Occupancy Permit - Extension <br /> Ease./Encroach <br />Required Information <br />Company or Vendor Name F.A. Wilhelm <br />New Vendor Yes If Yes, Approved by Purchasing <br /> No <br />MBE/WBE Contractor MBE <br /> WBE Completed E-Verify Form Attached Yes <br /> No <br />Project Name Commerce Center <br />Project Number <br />Funding Source <br />Account No. <br />Amount $10,200 <br />Terms of Contract <br />Purpose/Description Extend long term occupancy of LaSalle Avenue and Sycamore Street from <br />January 2021 through May 2021. <br />For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br />$ <br />($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />Increase <br />Decrease <br /> % <br />( %) <br /> New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br /> % <br />( %) <br /> Time Extension Amount: <br />New Completion Date: