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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date September 3, 0,1,9 <br />Name Charlotte Brach Department E ngineerin <br />BPW Date September 10 019 Phone Extension 9246 <br />ru rererere m�PPPPuuuuuuummmmmmmmmmmmmMmimom EJmi mor.......... wmmxrremmwmm wmmw,w.w.m'rvww,w,w.w.m'rvww,w,w.w.m'rvw <br />eq uired Prior to Submittal to Board <br />BPW Attorney <br />._ ......_._ �.�_....._ .,,,.. <br />ttorney Attorney Name <br />Dept. Attorney Attorney Name <br />Purchasing <br />. __._ Check the <br />i <br />ro ����� Item T __.___ �p <br />.._,_.., <br />El <br />ProfessionalServices Agreement <br />Contract <br />D <br />Open Market Contract <br />❑ Amendment/Addendum <br />E Bid Opening <br />❑ <br />Bid Award <br />Quote Opening <br />Quote Award <br />❑ Proposal Opening <br />F-1 <br />C/O & PCA No. <br />[� Chg. Order, No. <br />Traffic Control <br />Other: <br />Required Information <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 />All Submissions ssions <br />L Proposal <br />�] Special Purchase, QPA <br />❑ Req. to Advertise <br />Reject Bids/Quotes <br />PCA <br />❑ Resolution <br />Ease./Encroach <br />HRP Construction, Inc. <br />❑ Yes _ If Yes, Approved by Purchasing mmm� <br />No <br />MBE WBE Completed E-Verify Form Attached <br />Jackson Road Sanit <br />119-072 <br />Sewer Contractual <br />641.0621.792.63.35 <br />$115,820 <br />.......................................... <br />Base Quote <br />Amount of Increase $ <br />(❑ Decrease ($ ) <br />Previous Amount $ <br />Sewer Extension <br />Increase <br />Current Percent of Change: Decrease � .......,........" % <br />New Amount $ <br />Increase % <br />Total Percent of Change: Decrease <br />Time Extension Amount:. <br />New Completion Date: <br />❑ Title Sheet <br />Yes <br />No <br />