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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 02/04/2020 <br />Department Public <br />Name Zach Hurst Works <br />BPW Date 02/11/2020 Phone Extension 3057 <br />Eli mommmmmmmmmmmmmmommmm�MMMM000mmmmmMmmmm�MNMNMWWWWmmmm <br />..._...._,,,,,,,___..........,__.........................._.. .._ ._.........,�.,....�.�.... <br />Review and Approval Required Prior to Submittal to Board <br />..........................._._w ................_ <br />Diversity Compliance Officer Name <br />and Inclusion Officer El <br />BPW Attorney R Attorney Name <br />Dept. Attorney Attorney Name <br />Purchasing [❑ <br />Check the App170priilte Item'Type — <br />Professional Services Agreement Contract <br />❑ Open Market Contract <br />Z <br />Amendment/Addendum <br />E] <br />Bid Opening <br />E <br />Bid Award <br />El <br />Quote Opening <br />E] <br />Quote Award <br />E] <br />Proposal Opening <br />❑ C/O & PCA No. <br />Chg. Order, No. <br />❑ Traffic Control <br />❑ Other: <br />leq�a.mred Information <br />All Submissions <br />Proposal <br />Special Purchase, QPA <br />Req. to Advertise <br />EJ Reject Bids/Quotes <br />E] PCA <br />E] Resolution <br />El Ease./Encroach <br />❑ Title Sheel <br />Company or <br />"l"1o�camoIf <br />......... .....................w_��_.......m.__.�._......�����................��......_�_ mm� ... Yes, Approved by Purchasing <br />New VendorVendorName <br />No <br />❑ <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached ❑ Nos <br />WBE <br />Project Name <br />Cleveland Rd./Brick Rd. Pavement Improvementsmmmmmm ........ <br />Project Number <br />119-045 <br />Funding Source <br />---............ . .......................... <br />DA....................................... m.......__......�.�.�.�........................ w.— <br />Account No. <br />324-1050-460-31.02 <br />Amount <br />__.. <br />$720t1(10 <br />Terms of Contract <br />L......��..........................._....._�w�w�w... <br />ump Sum Contract � �� <br />m —w <br />Purpose/Description <br />Amendmmmexistin � " <br />1'SA to include water main d�si n services. Contrast <br />increases fi-om, $27,600 to $34,SQtD <br />�m .. For Change Orders <br />Amount of F Increase $......... .m. w................ ......._.. �s_—s s <br />Decrease ($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />New Completion Date: <br />Increase (% <br />................ <br />Decrease % <br />Increase % <br />Decrease (�% <br />