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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 09-10-2021 <br />Name: Jacob M. Klosinski, P.E.Department of Public Works – Engineering Division <br />BPW Date: 09-14-2021 Phone Extension:Ext. 9496 <br /> <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Clara McDaniels <br />Dept. Attorney Attorney Name Clara McDaniels <br /> <br />Purchasing Michael Schmidt <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: Ease./Encroach <br />Required Information <br />Company or Vendor Name <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 CSO 18 Backwater Valve Replacement <br />Project Number 120-017 <br />Funding Source 641-06-605-514-439001 <br />Account No. PR #00010974 /PO #TBD <br />Amount Refer to Purchase Requisition, Price will be based on awarded quotation <br />Terms of Contract Lump Sum, Unit Price <br />Special Contract Provisions <br />Purpose/Description Division of Engineering and Division of Utilities submits a request to Open <br />Quotations for the subject project for the replacement of the CSO 18 <br />Backwater Valve Replacement project at the 09/14/2021 Regular Meeting. <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 /> <br />New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br />% <br />(%) <br /> <br />Time Extension Amount: <br />New Completion Date: <br />