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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 09/29/2020 <br />Name Zach Hurst Department DPW <br />BPW Date 10/13/2020 Phone Extension 3057 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type — Re uired 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: ❑ Ease./Encroach <br />Information <br />Company or Vendor Name <br />❑ Yes If Yes, Approved by Purchasing <br />New Vendor <br />❑ No <br />❑ <br />MBE/WBE Contractor <br />Completed E-Verify Form Attached <br />❑ WBE ❑ Nos <br />Project Name <br />Former Salvation Army Building Roof Repairs <br />Project Number <br />119-084B <br />Funding Source <br />River West DA TIF <br />Account No. <br />PR-00004394 <br />Amount <br />Terms of Contract <br />Lump Sum <br />Purpose/Description <br />Quote request to perform roof repairs at the former Salvation Army building <br />For Change Orders Only <br />Amount of ❑ Increase $ <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 />Decrease ( % <br />Increase % <br />Decrease ( %) <br />