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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/14/20 <br />Name Ken Smith Department Utilities <br />BPW Date 12/17/20 Phone Extension 6108 <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 />Clara McDaniels <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 />N Other: Anneal n Ease./Encroach <br />Information <br />Company or Vendor Name <br />Cage Engineering <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 />Project Number <br />Funding Source <br />N/A <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description Appeal for water service for 215 Ireland Road. Requesting permission to <br />reconnect a service line, as prohibited in Section X, paragraph F on page 36 <br />outlined in the SBMU Rules and Regulations. Appeals must be brought before <br />the Board of Public Works. <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 />