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CITY OF SANTA ANA RE -BID <br />PROPOSAL <br />PROJECT NO.: 17-6876 <br />CROSSWALK UPGRADES PHASE II <br />FEDERAL PROJECT NO: HSIPL 5063(186) <br />INSTRUCTIONS — CONSTRUCTION CONTRACT DBE COMMITMENT <br />CONTRACTOR SECTION <br />1. Local Agency - Enter the name of the local agency that is administering the contract. <br />2. Contract DBE Goal - Enter the contract DBE, goal percentage as it appears on the project <br />advertisement. <br />3. Project Location - Enter the project location(s) as it appears on the project advertisement. <br />4. Project Description - Enter the project description as it appears on the project advertisement (Bridge <br />Rehab, Seismic Rehab, Overlay, Widening, etc). <br />5. Bidder's Name - Enter the contractor's firm name. <br />6. Prime Certified DBE - Check box if prime contractor is a certified DBE. <br />7. Bid Amount - Enter the total contract bid dollar amount for the prime contractor. <br />8. Total Dollar Amount for ALL Subcontractors — Enter the total dollar amount for all subcontracted <br />contractors. SUM = (DBEs + all Non -DBEs). Do not include the prime contractor information in this <br />count. <br />9. Total number of ALL subcontractors — Enter the total number of all subcontracted contractors. SUM <br />_ (DBEs + all Non -DBEs). Do not include the prime contractor information in this count. <br />10. Bid Item Number - Enter bid item number for work, services, or materials supplied to be provided. <br />11. Description of Work, Services, or Materials Supplied - Enter description of work, services, or <br />materials to be provided. Indicate all work to be performed by DBEs including work performed by the <br />prime contractor's own forces, if the prime is a DBE. If 100% of the item is not to be performed or <br />furnished by the DBE, describe the exact portion to be performed or furnished by the DBE. See LAPM <br />Chapter 9 to determine how to count the participation of DBE firms. <br />12. DBE Certification Number - Enter the DBE's Certification Identification Number. All DBEs must <br />be certified on the date bids are opened. <br />13. DRE Contact Information - Enter the name, address, and phone number of all DBE, subcontracted <br />contractors. Also, enter the prime contractor's name and phone number, if the prime is a DBE. <br />14, DBE Dollar Amount - Enter the subcontracted dollar amount of the work to be performed or service <br />to be provided. Include the prime contractor if the prime is a DBE. See LAPM Chapter 9 for how to count <br />full/partial participation. <br />15. Total Claimed DBE Participation - $: Enter the total dollar amounts entered in the "DBE Dollar <br />Amount" column. %: Enter the total DBE participation claimed ("Total Claimed DBE Participation <br />Dollars" divided by item "Bid Amount"). If the total % claimed is less than item "Contract DBE Goal," <br />an adequately documented Good Faith Effort (GFE) is required (see Exhibit 15-H DBE Information - <br />Good Faith Efforts of the LAPM). <br />16. Preparer's Signature - The person completing the DBE commitment form on behalf of the <br />contractor's firm must sign their name. <br />17. Date - Enter the date the DBE commitment form is signed by the contractor's preparer. <br />18. Preparer's Name - Enter the name of the person preparing and signing the contractor's DBE <br />commitment form. <br />19. Phone - Enter the area code and phone number of the person signing the contractor's DBE <br />commitment form. <br />20. Preparer's Title - Enter the position/title of the person signing the contractor's DBE commitment <br />form. <br />P-28 of P-42 RE -BID <br />20A-46 <br />