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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/23/2021 <br />Name Sue Ellen Doudrick Department DPW <br />BPW Date 12/14/2021 Phone Extension 5922 <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 <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: Emergency Repair <br />Memo <br /> Ease./Encroach <br />Required Information <br />Company or Vendor Name Selge <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 W Washington & Chapel Lane – Emergency Sewer Repair <br />Project Number 121-060 <br />Funding Source Sewer Utilities <br />Account No. 641-06-602-509-439001 <br />Amount $38,969.85 <br />Terms of Contract Lump Sum <br />Purpose/Description Emergency Repair of an 18” sewer in Dubail Avenue under Bowman Creek <br />For Change Orders Only <br />Amount of <br /> <br />Increase <br />Decrease <br /> <br />($) <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: 0 <br />New Completion Date: -