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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 1 /31 /23 <br />Name: Michael J Schmidt Department of Public Works — Engineering Division <br />BPW Date: 2/14/23 Phone Extension: <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Michael Schmidt <br />Dept. Attorney ❑ Attorney Name <br />Michael Schmidt <br />Purchasing ❑ <br />Mickey Low <br />Check the Appropriate <br />Item Type — Re uired or All Submissions <br />❑ Professional Services Agreement <br />❑ Contract <br />❑ Proposal <br />❑ Open Market Contract <br />❑ Amendment/Addendum <br />❑ Special Purchase, QPA <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Reject Bids/Quotes <br />❑ Proposal Opening <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />❑ Resolution <br />® Other: Memorandum of <br />® Ease./Encroach <br />nderstandin <br />Information <br />Company or Vendor Name AEP <br />New Vendor ❑ Yes❑ If Yes, Approved by Purchasing <br />❑ No <br />MBE/WBE Contractor ❑ ❑ <br />MBE Completed E-Verify Form Attached ❑ Nos <br />Easement located at the northwest corner of Kern Road and Michigan <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Special Contract Provisions <br />Purpose/Description <br />Street <br />MOU for an easement located at the northwest corner of Kern Road and <br />Michigan Street; Related Easement <br />For change Orders Only <br />Amount of ❑ Increase <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />Increase <br />Decrease <br />Increase <br />Decrease <br />New Completion Date: <br />