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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />April 17, 2018 <br />Roger T. Nawrot <br />Department <br />Division/Bureau <br />Public Works <br />Engineering <br />❑ <br />Agreement ❑ Contract U Proposal L...J Addendum <br />❑ <br />Professional Services ❑ Resolution <br />❑ <br />Bid Opening ® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ Quote Award <br />❑ <br />Change Order No. ❑ CIO & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ Traffic Control: <br />F� <br />Other: <br />Company or Vendor Name <br />Walsh & Kell <br />❑ Yes M No ❑ If Yes, Approved by <br />New Vendor <br />Purchasing <br />MBEIWBE Contractor <br />❑ <br />MBE ❑ WBE <br />MBEIWBE Contractor Requested <br />❑ <br />No ❑ Yes Name of Company <br />Project Name <br />Tucker Drive <br />Project Number <br />116-118A <br />Funding Source <br />RWTD <br />Account No. <br />324-1050-460.3102 <br />Amount <br />$283,972.77 <br />Terms of Contract <br />Purpose/Description <br />❑ Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Re u�red For Change Orders .Only <br />A ❑ Increase <br />Amount of <br />❑ Decrease <br />$ <br />$ <br />Previous Amount $ <br />Current Percent of Change: <br />% <br />New Amount $ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />