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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 8/3/20 <br />Name Liz Maradik Department DCI <br />BPW Date 8/11/20 Phone Extension x5821 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance <br />and Inclusion Officer El Officer Name <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ER Attorney Name Sandi Kennedy <br />Purchasing ❑ <br />Check the AppMriate Item Type — Required for All Submissions <br />LJ Professional Services Agreement LJ Contract LJ 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 />ER Other: MOU ❑ Ease./Encroach <br />Required Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Board of Commissioners of St. J <br />Yes❑ If Yes, Approved by Purchasing <br />No <br />❑ MBE Completed E-Verify Form Attached <br />❑ WBE <br />Transfer of Tax Sale Parcels <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount $ <br />Increase % <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />New Completion Date: <br />Decrease <br />Increase % <br />Decrease ( %) <br />❑ Yes <br />❑ No <br />