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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date1/21/20.............___.....__.....................____..__.....____..______........._.......___..... <br />Department <br />Name K le Silveus En ineerin <br />BPW Date 1/28/20 Phone Extension 9083 <br />_ w..W_._ ._.W w_WWwvi Y_..._-_ .. � _....W. <br />Review and A��ryal Required Prior to Submittal to Board <br />Diversity Compliance ❑ Officer Name <br />and Inclusion Officer <br />BPW Attorney ® Attorney Name Clara 1cDanlels <br />Dept. Attorney ❑ Attorney Name <br />................................... _.... _................. <br />Purchasing <br />...................... --- ._ _....... w....W _ <br />.l? p . <br />Check the Alr refs Item Type Rwit °e "y,, n- All Submissions <br />❑ Professional Services Agreement EJ Contract <br />❑ Open Market Contract <br />® Amendment/Addendum <br />❑] Bid Opening <br />❑ Bid Award <br />EJ Quote Opening <br />❑ Quote Award <br />F-1 Proposal Opening <br />❑ C/O & PCA No, <br />Chg. Order, No. <br />❑ Traffic Control <br />Other: <br />fl red Information <br />Proposal <br />H Special Purchase, QPA <br />❑ Req. to Advertise <br />❑ Reject Bids/Quotes <br />F-1 PCA <br />❑ Resolution <br />Ease./Encroach <br />❑ Title Sheel <br />Company or Vendor Name <br />DLZ <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 />Two Way Conversion of Colfax Ave., Phase 2 <br />Project Number <br />115-053 <br />Funding Source <br />WWDA <br />Account No. <br />422-1050-460-42-03 <br />Amount <br />................ <br />$53,523.00 <br />Terms of Contract <br />Supplement 3 for Design Services <br />Purpose/Description <br />Plan modifications to reduce scope and/or include alternate...__ .................................. n. <br />bids, additional <br />onal <br />lighting design and construction phase services, Rule 5 application, <br />conceptual bidding options. <br />For Chan e Orders Onl,�„ <br />Amount of <br />Increase$_ ...... ............................. u_..._.. ...._._. <br />Decrease <br />Previous Previous Amount <br />.................. <br />$ <br />.............................................w_ww.....w <br />........ ................... .._ <br />Increase % <br />Current Percent of Change: <br />Decrease ( /o)...._ <br />New Amount <br />$ <br />Increase % ............................................ . <br />Total Percent of Change: <br />Decrease ....... .....% <br />Time Extension Amount: <br />New Completion Date: <br />�........_.... ���������������.....................___......�����_... <br />