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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 08/14/2023 <br />Department Public <br />Name Scott <br />BPW Date 08/22/2023 Phone Extension 9245 <br />Required Prior to Submittal to Board <br />BPW Attorney ® Attorney Name Michael Schmidt <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ® Mikey Low <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 />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 />Purpose/Description <br />Information <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />❑ No <br />E] MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Cleveland Rd and Ameritech Dr Intersection Improvements <br />122-049 <br />River West TIF, MVH-R (PR-26179) <br />324-10-102-121-442001, 266-436008 <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 />New Completion Date: <br />Increase <br />Decrease <br />Increase <br />Decrease <br />