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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 04/02/19 <br />Name Alicia Czarnecki Department En ineearin <br />BPW Date 04/09/19 Phone Extension 5903 <br />MM <br />l aired Prior to Submittal to Board <br />BPW Attorney ® Attorney Name <br />Dept. Attorney ® Attorney Name <br />_._M .....WW <br />Purchasing z <br />Check the AppropriateItemType — Recj <br />L] Professional Services Agreement F] Contract <br />E] <br />Open Market Contract <br />n <br />Amendment/Addendum <br />[:] <br />Bid Opening <br />❑ <br />Bid Award <br />[l <br />Quote Opening <br />❑ <br />Quote Award <br />n <br />Proposal Opening <br />[ ] <br />C/O & PCA No. <br />❑' <br />Chg. Order, No. <br />F-1 <br />Traffic Control <br />F Other: <br />Reauirod Information <br />All Submissions <br />Proposal <br />Special Purchase, QPA <br />® Req. to Advertise <br />E] Reject Bids/Quotes <br />E] PCA <br />Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Company or Vendor Name <br />New Vendor YesEJ If Yes, Approved by Purchasing <br />❑ No <br />MBE/WBE Contractor MBE Completed E-Verify Form Attached ❑ Nos <br />Project Name 2019 Curb & Sidewalk iq <br />Project Number 119-004 <br />Funding Source MVH <br />�... _._._._._. ............... .-.._ ....... <br />Account No. 202-0619-431.31-06 <br />Amount .......................... <br />Terms of Contract <br />................................. ..---- <br />Purpose/Description <br />��.. <br />For Clit <br />.......n. E_ Orccrs Only <br />�..� <br />Amountof ❑ <br />Increase $ <br />......... <br />t cl Alwila '%' k�i <br />........ .._ ............... <br />❑ <br />Decrease ($ <br />Previous Amount <br />_ITITITITITITmm <br />' OE <br />Increase <br />% <br />Current Percent of Change: <br />Decrease <br />( %) <br />»a <br />New Amount <br />Increase <br />% <br />............... ._ ......................... <br />Total Percent of Change: <br />Decrease <br />( %) <br />Time Extension Amount: <br />New Com letion Date: <br />...._..........___.._ <br />