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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 05/02/2023 <br />Name Patrick Sherman Department Public Works <br />BPW Date 05/09/2023 Phone Extension <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />® Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ® Mickey Lovey <br />Check the Appropriate Item I <br />Professional Services Agreement ❑ Contract <br />❑ Open Market Contract <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Proposal Opening <br />❑ Chg. Order, No. <br />I-1 Other: <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 />Michael Schmidt <br />❑ Amendment/Addendum <br />❑ Bid Award <br />® Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />All Submissions <br />U Proposal <br />❑ Special Purchase, QPA <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Reject Bids/Quotes <br />❑ PCA <br />❑ Resolution <br />Ease./Encroach <br />Information <br />National Pavement Maintenance <br />Yes U If Yes, Approved by Purchasing <br />® No <br />❑ MBE Completed E-Verify Form Attached ❑ Yes <br />No <br />Century Center Parking Lot Seal and Stripe <br />122-060B <br />PR-00024012 <br />Fund 7304 <br />$49,123.50 <br />Unit Price <br />_Seal and stripe of Century Center Parking lot including limited asphalt <br />repair. <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 />Increase <br />Decrease <br />Increase <br />Decrease <br />New Completion Date: <br />