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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 10/27/2023 <br />Name: Chana Roschyk Department of Public Works — Engineering Division <br />BPW Date: 11/14/23 Phone Extension: 5922 <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <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 />n Other: n 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 />Information <br />NA <br />❑ Yes[:] If Yes, Approved by Purchasing <br />❑ No <br />❑ WBE Completed E-Verify Form Attached 1:1 Yes <br />❑ No <br />Greenlake Dr. and York Rd. <br />TR23-030 <br />NA <br />nn�#-NA <br />NA <br />NA <br />NA <br />Stop sign installation on Greenlake Dr. at York Rd <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 />