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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/27/2024 <br />Name Kvle Ludlow Department Public Works <br />BPW Date 01/14/2025 Phone Extension 9157 <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 ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type — Re uired or 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 />n Other: n Ease. /Encroach <br />Company or Vendor Name Acorn 1 <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 />Information <br />U Yes U If Yes, Approved by Purchasing <br />® No <br />MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Riverside Shoulder Repair <br />124-059 <br />Local Roads & Bridges <br />PR-00035803 PO-0033905 <br />$17,569.00 <br />Purpose/Description _Project Closeout <br />For Change Orders Only <br />Amount of Increase $ <br />Previous Amount <br />❑ Decrease <br />Current Percent of Change <br />New Amount <br />Increase <br />Decrease <br />Increase <br />Total Percent of Change: Decrease <br />Time Extension Amount: <br />New Completion Date: <br />