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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/28/2023 <br />Name Scott Kreeger <br />Department Public <br />Works <br />BPW Date 7/11/2023 Phone Extension 9245 <br /> <br />Required Prior to Submittal to Board BPW Attorney Attorney Name Michael Schmidt <br />Dept. Attorney Attorney Name <br /> <br />Purchasing Mickey Lovy <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 <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 2023 Microsurfacing Quote <br />Project Number 123-023 <br />Funding Source Local Income Tax <br />Account No. 408-06-602-503-436008 <br />Amount <br />Terms of Contract <br />Purpose/Description <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 />