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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />December 4, 2017 <br />Roger Nawrot <br />Department <br />Division/Bureau <br />Engineering <br />DPW <br />BPW Date 12/12/17 Phone Extension 5933 <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />® Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control: <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBEANBE Contractor <br />MBEIWBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑ Increase <br />Decrease <br />Selge Construction Co., Inc. <br />_❑ Yes ® No ❑ If Yes, Approved by <br />❑ MBE ❑ WBE <br />❑ No ® Yes Name of Company Martell <br />College Avenue & Sunn mede Avenue Traffic Calming <br />117-113 <br />LRSA <br />251-0608-431.42-96 <br />$37,400.00 <br />Completion date of <br />U Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Coy Original <br />❑ ❑ <br />