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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 0 /2 /2024 <br />Name Department Public Works <br />BPW Date 0 //2024 Phone Extension 5 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer Officer Name <br />BPW Attorney Attorney Name Michael Schmidt <br />Dept. Attorney Attorney Name <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 <br />Project Number N/A <br />Funding Source PR-0003 <br />Account No. 201-11-201-201-43600 -- <br />Amount $ <br />Terms of Contract Lump Sum Quote <br />Purpose/Description <br /> <br />For Change Orders Only <br />Amount of 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: