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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 06/19/2018 <br />Name <br />Kyle Silveus <br />Department <br />Engineering <br />BPW Date <br />06/26/2018 <br />Phone Extension <br />9083 <br />❑ Agreement <br />❑ Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ Resolution <br />❑ <br />Bid Opening <br />® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ <br />CIO & PCA No. ❑PCA <br />❑ Ease/Encroach. <br />❑ <br />Traffic Control <br />❑ Other: <br />Company or Vendor Name <br />Sel e Construction Inc. <br />New Vendor <br />❑ Yes ]A No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBEMIBE Contractor Requested Fj No ❑ Yes Name of Company <br />Project Name <br />LWW Charles Martin Intersection Improvements <br />Project Number <br />117-072A <br />Funding Source <br />RWDA <br />Account No. <br />324-1050-460-42.03 <br />Amount <br />$ 1,131,012.15 <br />Terms of Contract <br />Base bid <br />Purpose/Description <br />Intersection Improvements at Lincolnway West and Charles Martin <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Amount of ❑ <br />El <br />Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change; <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />% <br />Dispersal After Approval <br />