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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 8/6/2024 <br />Name Leslie Biek Department Engineering <br />BPW Date 8/13/2024 Phone Extension 9322 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney ® Attorney Name <br />Dept. Attorney ❑ <br />Attorney Name <br />Michael Schmidt <br />Purchasing ® Ron O'Connor <br />Check the Appropriate Item Type — Re uired or All Submissions <br />® Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Proposal Opening <br />❑ Chg. Order, No. <br />I-1 Other: <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 />❑ Amendment/Addendum <br />❑ Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />Information <br />Jones Petrie Rafinski Co <br />❑ Special Purchase, QPA <br />❑ Req. to Advertise ❑Title Shei <br />❑ Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />® No <br />❑ ❑ <br />MBE Completed E-Verify Form Attached ❑ Nos <br />Portage and Cleveland Traffic Signal Improvement <br />123-063: PROJ 548 <br />PR 35315 <br />251-436010 <br />$29,000 <br />60 calendar days from NTP <br />PSA for the Traffic Signal Improvements at the Portage Ave and <br />Cleveland Rd intersection <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 />