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<br />• <br />Local Agency Bidder DBE Information (Construction Contracts) <br />• <br />• <br />AGENCY: r/-T~ O~ SAfJT~ ~tfSl A LOCATION: PROJF,CT NO 08-5023: TRAFFIC SIGNAL MODIFICATION ON <br />SANTA AN BLVD & FLOWER ST <br />PROJECT DESCRIPTION: T2AFF 1 L SL UN ~L, 1 LJ STALL,AT~'J <br />OTAL CONTRACT AMOUNT: $ ~ ~ ~ ~C ' <br />ID DATE: ~Z'~>' (~ <br />BIDDER'S NAME: LINCOLN PACIFlC BUILDERS, INC <br />ONTRACT <br />ITEM NO. ITEM OF WORK AND DESCRIPTION <br />R SERVICES TO BE <br />SUBCONTRACTED OR MATERIALS <br />O BE PROVIDED BE Cert. No. <br />ND EXPIRATION <br />ATE NAME OF DBEs <br />(Must be certified on the date bids <br />are opened -include DBE address <br />nd hone num er) DOLLAR AMOUNT <br />DBE <br /> <br /> Ll <br /> DvJ nl <br /> Ob <br /> 0 ~~ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />or Local Agency to Complete: <br />Total Claimed <br />~ ~ ZS~ QV Q , <br />cal Agency Contract Number: <br />Federal Aid Project Number: <br />Federal Shaze: $4,509 Participation <br /> <br />f) <br />Contract Award Date: <br />Local Agency certifies that the DBE certification(s) has been verified and all <br />information is complete and accurate. <br />~__ <br /> <br />Print Name Signature Date Signatu of Bidder Ce ~ 1 <br />t72 Z~ LO G~bO'"J,138 <br />ocal Agency Representative <br />(Area Code) Tele hone Number: Date (Area Code) Tel. No. <br /> <br />~ <br /> I.IN~°u~ ~~` <br />or Caltrans Review: <br />Print Name Signature Date <br />Caltrans District Local Assistance Engineer Person to Contact (Please Type or Print} <br /> <br /> <br />Local Agency Bidder DBE Information (I~eo 3/09) <br />u~sMbuuon: (1) Copy - h'ax or scan a copy to the Caltrans District Local Assistance Engineer (DEAF) within 15 days of contract execution. Failure to send <br />a copy to the DLAE within I S days of contract execution may result in the de-obligation of funds for this project. <br />(2) Copy -Include in award package to Caltrans District Local Assistance <br />(3) Original -Local agency files <br />TO BE INCLUDED IN BID PACKAGE <br />BP 26 of 34 <br />