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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11 /19/18 Department Public Works <br />Name Kyle Silveus Division/Bureau Engineering <br />Purchasing E] <br />Check the <br />H Agreement <br />El Professional Service <br />F] Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />Other: Dedicated Imo <br />Michael Schmidt <br />iro riate Item Type — <br />F Contract <br />s ❑ Resolution <br />❑ Bid Award <br />❑' Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control: <br />rovements Agreement <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />for All Submissions <br />] Proposal <br />❑ Req. to Advertise <br />uired Information <br />Menards Development <br />..... <br />DP 1 .... <br />7-014 <br />N/A <br />N/A <br />N/A <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />Terms of Contract N/A <br />................ ............ _....._.. ....._... .........._. <br />Purpose/Description Dedicated Improvements Agreement for signature, which includes: <br />Performance Bond @ 125% of Construction Cost of work in ROW <br />3 year Maintenance Bond @ 10% of the construction cost of work in <br />ROW, Certificate of Insurance <br />F Required Contractor's Certification Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change, Orders Onl <br />Amount of El Increase $ ...... .. ......... ......_.. _......._. <br />[] Decrease $ <br />Previous Amount ..$....._...... ...... _____�._............. ._......_...... <br />Current Percent of Change; % <br />New Amount $ <br />Total Percent of Chanae: <br />Dispersal After Awroval <br />Copy <br />Original <br />❑ <br />F] <br />❑'EJ <br />n <br />