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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/27/2023 <br />Name Becca Plantz <br />Department Public Works <br />BPW Date 12/12/2023 <br />Phone Extension 5998 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />and Inclusion Officer <br />Officer Name <br />Cynthia Simmons <br />BPW Attorney ❑ <br />Attorney Name <br />Michael Schmidt <br />Dept. Attorney ❑ <br />Attorney Name <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type <br />— Re uired or All Submissions <br />❑ Professional Services Agreement <br />❑ Open Market Contract <br />❑ Bid Opening <br />® Quote Opening <br />❑ Proposal Opening <br />❑ Chg. Order, No. <br />❑ Other: <br />❑ Contract ❑ Proposal <br />❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Award ❑ Reject Bids/Quotes <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control ❑ Resolution <br />❑ Ease./Encroach <br />Reauired Information <br />Company or Vendor Name <br />❑ Yes❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />❑ MBE ❑ Yes <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />❑ WBE ❑ No <br />Project Name <br />Northwest Elevated Tank Site Restoration <br />Project Number <br />122-018A <br />Funding Source <br />Water Works Capital — Distribution/ Reservoirs <br />Account No. <br />PR-00029295 <br />Amount <br />Terms of Contract <br />Lump Sum <br />Purpose/Description <br />Site restoration of the Northwest Elevated Tank lot after damage from <br />painting operations of the tank. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount $ <br />Increase <br />Current Percent of Change: Decrease <br />New Amount $ <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />