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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date Se tember 1.7 11191 <br />Name Charlotte Brach Department Engineering <br />BPW Date Se tembr 4 2019 Phone Extension 9246 <br />u wIliimmmmmmmmmmom" <br />Re uired Prior to Submittal to Board <br />BPW Attorney Attorney Name <br />Dept. Attorney Attorney Name <br />Purchasing❑ <br />_ Check the pprit Item �.�F�-.Re rzi <br />El Professional Services Agreement ❑ Contract <br />Open Market Contract ❑ Amendment/Addendum <br />El Bid Opening ® Bid Award <br />F-1 Quote Opening ❑ Quote Award <br />f Proposal Opening C/O & PICA No. <br />Chg. Order, No. El Traffic Control <br />E] Other: <br />l�uite Information <br />llbr Submissions <br />Proposal <br />E] Special Purchase, QPA <br />El Req. to Advertise <br />E] Reject Bids/Quotes <br />❑ PICA <br />❑ Resolution <br />Ease./Encroach <br />❑ Title Sheet <br />Company or Vendor Name <br />Midland Engineering a .................. �, <br />❑ Yes❑ If Yes, Approved by Purchasing <br />New Vendor <br />No <br />MBE ❑ Yes <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />WBE ❑ No <br />Project Name <br />Vested Interest Building Roof Repair <br />Project Number <br />m.�,�,. .......... ww_ <br />119-049 <br />Funding Source <br />RWDA TIF <br />Account No. <br />324-1050-460-42.02 <br />Amount <br />$226,800 <br />Terms of Contract <br />..�.Base..........................................._w................................................w _� ....� <br />Bid <br />Purpose/Description <br />Award subject to RDC approval _ of amended agreement w�i.t..h. ............ Ziker Sample <br />Street, LLC. <br />For Chan em Orders Onl <br />Amount of ❑ <br />Increase $ <br />❑ <br />Decrease $ <br />Previous Amount <br />$ ...................................................................................... <br />......................................%. <br />......................w�w�ww..__ <br />Increase <br />�, _.._ <br />Current Percent of Change: <br />Decrease ( <br />/ <br />New Amount <br />$ <br />Increase �m...... <br />/o <br />Total Percent of Change: <br />Decrease ( <br />.............%) <br />_....... aa_.— �� <br />Time Extension Amount: <br />New Completion Date: <br />