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Local Agency~dder DBE Information (Const~tion Contracts) <br />• <br />• <br />• <br />GENCY: ~~~ ~ qN't A ~N A LOCATION: PROJECT NO 08-5018: TRAFFIC SIGNAL INSTALLATION ON <br />}IAZARD AVE & ROSITA ST <br />ROJECT DESCRIPTION: T(LgSti~ ~ .. S t~ N h <br />OTAL CONTRACT AMOUNT://$ ~~ Q . S ~ Lo . ~I D <br />ID DATE: 3~3[ ~O <br />IDDER'S NAME: TQ {Zu p _ 1 N ~ <br />ONTRACT <br />ITEM NO. TEM OF WORK AND DESCRIPTION <br />R SERVICES TO BE <br />UBCONTRACTED OR MATERIALS <br />O BE PROVIDED BE Cert. No. <br />ND EXPIRATION <br />ATE AME OF DBEs <br />Must be certified on the date bids <br />re opened -include DBE address <br />nd hone number) LLAR AMOUNT <br />BE <br /> Q d <br /> 3t~ <br /> Oo - ? -5 0 <br /> <br /> <br /> 2 p OD. (o <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />For Local Agency to Complete: <br />al A enc Contract Number: <br />g Y <br />ederal Aid Project Number: <br />ederal Share: 7 120 <br />Total Claimed <br />Participation <br />$ 2 p, gOd ~ <br />ontract Award Date: <br />cal Agency certifies that the DBE certification(s) has been verified and all <br />information is complete and accurate. i <br />`~~ - ~'~ <br /> <br /> <br />rint Name Signature Date Signature of Bid <br />i <br />3 ~3 '~ l 2.2 g ~ (0 3 1 <br />al Agency Representative <br />Area Code) Telephone Number: Date (Area Code) Tel. No. <br />` <br /> <br />C <br />lt <br />R <br />i ~ <br />~~ d- u.. Acd A <br />or <br />a <br />rans <br />ev <br />ew: <br />Print Name Signature Date <br />Caltrans District Local Assistance Engineer Person to Contact lease Type or Print) <br /> <br /> <br />Local Agency Bidder DBE Infomtation (Rev 3/09) <br />Lisu ~ouuun: t i ~ ~.opy - rax or scan a copy to the ~:a~trans lltstnct Local Assistance Engineer (DEAF) within 15 days of contract execution. Failure to send <br />a copy to the DLAE within 15 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 />BP 20 of 32 <br />TO BE INCLUDED IN BID PACKAGE <br />