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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11/27/2023 <br />Name Becca Plantz Department Public Works <br />BPW Date 12/12/2023 Phone Extension 5998 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ Officer Name Cynthia Simmons <br />and Inclusion Officer <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing <br />0 <br />Michael Schmidt <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 />❑ WBE Completed E-Verify Form Attached ❑ Yes <br />No <br />Northwest Elevated Tank Valve Vault Coating <br />122-018B <br />Water Works Capital — Distribution/ Reservoirs <br />PR-00029298 <br />Lump Sum <br />Removing and reapplying failing insulative coating on the valves in the vault <br />for the Northwest Elevated Tank. <br />Ir 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 />