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Local Agenc~idder DBE Information (Const~ction Contracts) <br />• <br />• <br />• <br />GENCY: ~ ~ ~ ~ ~ ~ {~ w~ i1 N (~ LOCATION: PROJECT NO 08-5020: TRAFFIC SIGNAL MODIFICATION ON <br />c MCFADDEN AVE & NEWHOPE AVE <br />ROJECT DESCRIPTION: Tl~~ } ~ ~ ~ ~a, w (~ <br />OTAL CONTRACT AMOUNT: $ ~ Z~I, S 3"7r 3 O <br />r <br />ID DATE: 3 f 3~`O <br />IDDER'S NAME: T~ (Z,~O , TN ~, <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 />2\ ~ 30 <br /> <br /> OJ- -5 n <br /> <br /> <br /> S ~ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />or Local Agency to Complete: <br /> <br />al Agency Contract Number: <br />Total Claimed <br />$ S --~ ~ <br /> <br />ederal Aid Project Number: <br />ederal Share: 4 234 Participation <br /> <br />~~ % <br />ontract Award Date: _ <br />al Agency certifies that the DBE certification(s) has been verified and all <br />information is complete and accurate. <br /> <br />rint Name Signature Date Signature of Bidd 44 <br />3 - 2.2 L ~ ~ ro~J <br />Local Agency Representative <br />Area Code) Tele hone Number: Date (Area Code) Tel. No. <br />^ <br /> <br />or Caltrans Review: <br />Print Name Signature Date <br />Caltrans District Local Assistance Engineer y{ LCD /\ri a u~ A (~1 Lv (~ <br />Person to Contact (Please ype or Print) <br /> <br /> <br />Local Agency Bidder DBE Infomration (Rev 3/09) <br />.~~~~~ wuu~u. ~ ~ ~ wpy - rax ur scan a copy to me ~aitrans llistnct t.ocai Assistance lrngrneer (llLAE) within 15 days of contract execution. Failure to <br />send 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 24 of 32 <br />TO BE INCLUDED IN BID PACKAGE <br />