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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 04/28/2023 <br />Name Becca Plantz Department Public Works <br />BPW Date 05/09/2023 Phone Extension 5998 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item I <br />Professional Services Agreement ❑ Contract <br />❑ Open Market Contract <br />® Bid Opening <br />❑ Quote Opening <br />❑ Proposal Opening <br />❑ Chg. Order, No. <br />I-1 Other: <br />Michael Schmidt <br />❑ Amendment/Addendum <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />Information <br />All Submissions <br />U Proposal <br />❑ Special Purchase, QPA <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />Company or Vendor Name <br />❑ Yes❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />Yes <br />❑❑ ❑ <br />MBE <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached ❑ <br />No <br />Project Name <br />Johnson & Fellows Intersection Drainage Improvements <br />Project Number <br />122-016A <br />Funding Source <br />Stormwater Infrastructure <br />Account No. <br />PR-24005 <br />Amount <br />Terms of Contract <br />Unit Prices <br />Purpose/Description <br />Drainage improvements at the northeast quadrant of the intersection of <br />Johnson Street and Fellows Street. <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 />