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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2/18/2020 <br />.._.����..�� <br />Department Public Works <br />Name SueEllenDoudrick..........a <br />- <br />.......... ..... .............................. _ <br />Division/Bureau Engineering ............_ <br />BPW Date 2/25/2020 <br />Phone Extension 5922 <br />-....- <br />Required -_ <br />Prior to Submittal to Board , <br />Legal <br />Attorney Name: - <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in <br />length per the City Purchasing Policy <br />Purchasing [� <br />Michael Schmidt <br />.�_�.... a <br />[ Ch—ec.kthe riate Item'Te —Re Required <br />_.._....... ......... <br />olSubmissins <br />� Agreement Amendment g <br />Contract <br />El Proposal 0 Addendum <br />[� Professional Services <br />El <br />Resolution <br />Bid Opening <br />❑ <br />Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />El <br />Quote Opening <br />R <br />Quote Award <br />R <br />Change Order No. <br />C/O & PCA No. <br />❑ PCA <br />El <br />Ease/Encroach. <br />R <br />Traffic Control: <br />Other: <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBE/WBE Contractor Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of El Increase <br />[] Decrease <br />Previous Amount $ <br />Current Percent of Change:. <br />New Amount $ <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />11 <br />1:1 <br />0 <br />❑ <br />HWC Enaineerin <br />❑ Yes ® No ❑ If Yes, Approved by <br />_mmPurchasi �............................ <br />w <br />❑ MBE ❑ WBE <br />No ❑Yes Name of Compap mmWWW� <br />Prairie Avenue Water Main Loop <br />117-068 <br />Water Professional Services ITITITmm <br />_...... ........ <br />620-0640-658-3102 Engineering.....-,_ <br />$32,395 (Previous Amount $192,500; P.O. Total $224,895) <br />Unit Prices <br />..................................­.................................... __ <br />Amendment No. 2 is for re -submittal of permits, utility <br />coordination, appraisals, atisition services. <br />Required Contractor's c <br />ctor s Certification ....................... �� <br />❑ qred ation Forms Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />_WW_.__._.... .. <br />Required For Change Orders Only <br />Disoersal After Aooroval <br />