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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/13/2022 <br />Name Leslie Biek, PE Department Public Works <br />BPW Date 12/20/2022 Phone Extension 9323 <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: Ease. /Encroach <br />Required Information <br />Company or Vendor Name Milestone Contractors North, 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 Sample and Mayflower Intersection Improvements <br />Project Number 120-052R <br />Funding Source <br />Account No. PO 10526 <br />Amount <br />Terms of Contract <br />Purpose/Description _Project Closeout <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: <br />