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Date: <br />Name: <br />BPW Date: <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />2/20/2023 <br />Daniel Sexton Department of Public Works — Engineering Division <br />2/28/2023 <br />Phone Extension: <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />5903 <br />Check the Appropriate Item Type -- Re aired br 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 L] 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 />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <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 />ired Information <br />n/a <br />❑ Yes❑ If Yes, Approved by Purchasing <br />❑ No <br />❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />n/a <br />TR22-082 <br />n/a <br />PR/PO # n/a <br />n/a <br />n/a <br />n/a <br />See attached memo for multi -way stop warrant analysis and design for sign <br />placements. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Increase <br />Decrease <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />