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BOARD OF PUBLIC WORKS
<br />AGENDA ITEM REVIEW REQUEST FORM
<br />Date 07/05/2019
<br />,17011 Name 1 oy i I la
<br />...... -----. -----
<br />Department: Engineering _ ..�.�.
<br />BPW Date 07/23/2019 Phone Extension 5920
<br />' :'�4'd-4'NdYXM ..1Vu�. d fu c935 ra�dip�,y�gWSy?A. fWdYfiBx.. u^,�B &dGiM�IFwM✓ Se/e'uw„, LkWWWIIm'I�VlYNN9MwVplulul!WWI e'�2'�' IIIIIIPiu@IUIIIIIIM 1 .. " ,MEMM rMMON .+:
<br />...................��„��,,,,,,,,��,,,,,,,.,..,.,.,,.,,,,,,,,,,,,,,,,,,,,,,,,.,,.,,...................W...................... ����,.........,,,,,,,,,,,........_..,,,..,, _
<br />Re uired Prior t _�.�.0 _.... t q Board
<br />o Submittal to Boa
<br />BPW Attorney ❑ Attorney Name
<br />Dept. Attorney ❑ Attorney Name
<br />Purchasing
<br />--- ------ ..._ �.
<br />Check the Avou..onfiate Item Tvne Reaulred
<br />LJ Professional Services Agreement L_J Contract
<br />[J
<br />Open Market Contract
<br />Amendment/Addendum
<br />Bid Opening
<br />Bid Award
<br />Quote Opening ❑
<br />Quote Award
<br />Proposal Opening ❑
<br />C/O &PCA No.
<br />Z
<br />Chg. Order, No. 1 ❑
<br />Traffic Control
<br />❑ Other:
<br />Company or Vendor Name
<br />New Vendor
<br />MBE/WBE Contractor
<br />Project Name
<br />Project Number
<br />Funding Source
<br />Account No.
<br />Amount
<br />Terms of Contract
<br />Purpose/Description
<br />Information
<br />All Submissions
<br />Proposal
<br />F] Special Purchase, QPA
<br />❑ Req. to Advertise ❑ Title Sheet
<br />F-1 Reject Bids/Quotes
<br />PCA
<br />Resolution
<br />Ease./Encroach
<br />Pemberton_ -Davis Electric, Inc. _
<br />Yes If Yes, Approved �
<br />�❑ ❑ pP Y Purchasing
<br />® No
<br />❑ MBE Completed E-Verify Form Attached E]Yes
<br />WBE ❑j No
<br />........ i Mishawaka Avenue Traffic Si nals at Fire Station _mon #9y„ ___ m.�..........
<br />117-120A
<br />Div. A - LRSA Traffic Signal Maintenance / Div. B......................
<br />-EMS Capital
<br />Fund
<br />�... ............... - - --_ m...m.,mm._ ..m._. ......_.
<br />1.0608.431.36.67 / 287.0902.422.42.02
<br />AVproval of C.O. #1
<br />Change Orders On ...__ ��. .�
<br />�............._...µ........... _ For .................. aY _____----__
<br />Amount of z Increase $ 16,638.57
<br />[ j Decrease ($ )
<br />....................
<br />Previous Amount $ 171,2
<br />........... ---_____-
<br />. .. M_..
<br />85.37
<br />.e�Increase... ... 9.71 %.... ...�., �—_......, ....... ..W�.
<br />Current Percent of Change: Decrease,_ �m ..m.,%).,_ .. New Amount $ 187,923.94
<br />...........................................
<br />Increase %
<br />�.............................. ........ ..
<br />----------------
<br />Total Percent of Change: Decrease'9.71%
<br />Time Extension Amount:
<br />..... -- ......... ----- ------ ----.___...-_...................__..... ...... ........ _..... .—
<br />New Completion Date:
<br />
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