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Local Agency~dder DBE Information (Const~tion Contracts) <br />• <br />• <br />• <br />GENCY: ~','Cy 0 ~ ~ t3e7~FA kt1~41 <br /> <br />ROJECT DESCRII'TION: T n p~ ~t~ S ~~, ~ <br />OTAL CONTRACT AMOUNT: $ \~ \ , \4 <br />ID DATE:_ 3/~Jl~ O <br />IDDER'S NAME: ~Q ~N O , ~ ~ ~ LOCATION: <br /> <br />R\ <br />2 , O b PROJECT NO 08-5019: TRAFFIC SIGNAL INSTALLATION ON <br />HAZARD E/O GATES ST <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) OLLAR AMOUNT <br />BE <br />\3 L o ~ lQ ~ ~ 3\ 3 ~1~ <br /> 3- _1Z <br /> '] - 5 (o d <br /> <br /> 3 .O <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />For Local Agency to Complete: <br /> <br />Local Agency Contract Number: <br />ederal Aid Project Number: <br />ederal Share: 6 982 <br />Total Claimed <br />Participation <br />$ \ p\ \3 ~ ~ 0 <br />~ <br /> <br />~` % <br />ontract Award Date: <br />i~ <br />cal Agency certifies that the DBE certification(s) has been <br />information is complete and accurate. verified and all ~~ <br /> <br />_ ~ b <br /> <br /> <br />~nt Name Signature <br /> <br />Date Signature of Bidt1 <br />G/ <br />3 3 ~ ! i.~ \ ~{ - 22 Q - q V 3 ~ <br />al Agency Representative <br />Area Code) Tele hone Number: Date i (Area Code) Tel. No. <br />For C <br />lt <br />R <br />i a,R. K <br />a <br />rans <br />ev <br />ew: <br />Print Name Signature <br />Caltrans District Local Assistance Engineer <br />Date Person to Contact (Please T e or Print) <br /> <br /> <br />Local Agency Bidder DBE Information (Rev 3/09) <br />--•.. •••.~..~•.~... ~.~ ...,t,y -, an v~ a~au a wNy w uw i.aui aun L~SLnGI WCaI Hs5lSiance cnglneei (ULAts) Wlthln 1~ days of COntiact exeCUtlOn. FflllUre t0 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 22 of 32 <br />TO BE INCLUDED IN BID PACKAGE <br />