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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/12/2021 <br />Name Serena Lozano -Shane Department Utilities <br />BPW Date 3/23/2021 Phone Extension 5798 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ Officer Name <br />and Inclusion Officer <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing <br />0 <br />Check the Appropriate <br />Item Type — Re aired for All Submissions <br />❑ <br />Professional Services Agreement <br />❑ Contract <br />❑ Proposal <br />❑ <br />Open Market Contract <br />❑ Amendment/Addendum <br />❑ <br />Special Purchase, QPA <br />❑ Bid Opening <br />❑ Bid Award <br />❑ <br />Req. to Advertise ❑ Title Sheel <br />❑ Quote Opening <br />❑ Quote Award <br />❑ <br />Reject Bids/Quotes <br />❑ <br />Proposal Opening <br />❑ <br />C/O & PCA No. <br />❑ PCA <br />❑ <br />Chg. Order, No. <br />❑ <br />Traffic Control <br />❑ Resolution <br />x❑ Other: Industrial Permit <br />Previous Amount <br />❑ Ease./Encroach <br />Renewal :ITU AbsorbTech, Inc <br />Increase % <br />Current Percent of Change: <br />Required Information <br />Company or Vendor Name <br />❑ Yes❑ If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />MBE/WBE Contractor <br />❑ MBE Completed E -Verify Form Attached F] Yes <br />❑ WBE ❑ No <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />For Change Orders Only <br />Amount of ❑ <br />Increase $ <br />❑ <br />Decrease $ <br />Previous Amount <br />$ <br />Increase % <br />Current Percent of Change: <br />Decrease ( %) <br />New Amount <br />$ <br />Increase % <br />Total Percent of Change: <br />Decrease <br />Time Extension Amount: <br />New Completion Date: <br />