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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/17/20 <br />Department <br />Name Kyle Silveus Engineering <br />BPW Date 6/23/20 Phone Extension 9083 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer ❑ Officer Name <br />BPW Attorney ® Attorney Name Clara McDaniels <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type — Reuirec or All Submissions <br />❑ Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PCA No. ❑ PCA <br />❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution <br />® Other: Water Main ❑ Ease./Encroach <br />Extension Agreement <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Proj ect Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />Patrick O'Brien Enterprises, LLC <br />❑ Yes❑ If Yes, Approved by Purchasing <br />❑ No <br />E] MBE <br />❑ WBE Completed E-Verify Form Attached ❑ Yes <br />No <br />Hill and St. Vincent — Water Main Extension <br />DP20-003 <br />N/A <br />N/A <br />N/A <br />N/A <br />Private Extension of Public Water Main. <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <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 Combletion Date: <br />