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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 12/10/2024 <br />Name: Gemma Stanton Department of Public Works – Engineering Division <br />BPW Date: 12/17/2024 Phone Extension: 9083 <br />Required Prior to Submittal to Board <br />BPW Attorney 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. 1 Traffic Control Resolution <br /> Other: Ease./Encroach <br />Required Information <br />Company or Vendor Name Selge Construction (Div. 1, 2, & 3) <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 2024 Curb and Sidewalk Program <br />Project Number 124-009 <br />Funding Source Motor Vehicle Highway <br />Account No. <br />Division 1 PO – 0032684; Division 2 PO – 0032686; Division 3 PO – <br />0032683 <br />Amount See attached memo <br />Terms of Contract Unit price <br />Special Contract Provisions N/A <br />Purpose/Description Change order for additional sidewalk completed <br />For Change Orders Only <br />Amount of Increase <br />Decrease <br />$ See attached memo <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: