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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 05/11/2021 <br />Name Toy Villa Department Public Works <br />BPW Date 05/25/2021 Phone Extension 5920 <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 />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 Selge Construction Co., Inc. <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 Star 001 – Proposed C-Store and Gas Station <br />Project Number DP18-025 <br />Funding Source <br />Account No. <br />Amount $190,000.00 <br />Terms of Contract <br />Purpose/Description _Project Closeout <br />For Change Orders Only <br />Amount of Increase <br />Decrease <br />$ <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: