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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date February 15, 2021 <br />Name Kyle Silveus <br />Department <br />Engineering <br />BPW Date February 23, 2021 Phone Extension <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 –Required for 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: Agreement Ease./Encroach <br />Required Information <br />Company or Vendor Name Four Horsemen Ventures, LLC <br />New Vendor Yes If Yes, Approved by Purchasing <br />No <br />MBE/WBE Contractor MBE <br />WBE Completed E-Verify Form Attached Yes <br />No <br />Project Name Belle Terre Sewer Facility Agreement and Right of Entry License <br />Project Number DP19-049 <br />Funding Source N/A <br />Account No. N/A <br />Amount N/A <br />Terms of Contract <br />Purpose/Description Outlines the terms to allow a private sewer connection to a Public Sewer <br />Manhole <br />For Change Orders Only <br />Amount of Increase <br />Decrease <br />$ <br />($ ) <br />Previous Amount $ <br />Current Percent of Change: <br />Increase <br />Decrease <br />% <br />(%) <br /> New Amount $ <br />Total Percent of Change: <br />Increase <br />Decrease <br />% <br />(%) <br />Time Extension Amount: <br />New Completion Date: