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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/13/2022 <br />Name Toy Villa Department Public Works <br />BPW Date 12/20/2022 Phone Extension 5920 <br />Required Prior to Submittal to Board <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 Asphalt Restoration Services <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 2022 Contracted Crack Sealing <br />Project Number PROJ0000000336 <br />Funding Source Infrastructure Bond <br />Account No. 455-442001 <br />Amount $92,000.00 <br />Terms of Contract <br />Purpose/Description __Project Closeout <br />For Change Orders Only <br />Amount of Increase <br />Decrease <br />$ <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: