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Local Agency BIDDER-DBE (Construction Contracts}Information <br />successful BIDDER must execute and return the LOCAL AGENCY BIDDER -DBE IIVFORMAT70N forth, even if no DBE <br />icipation will be reported. <br />AGENCY: ' v vi Ffi?_¢ LOCATION: ori.?, s4 .Arv' « ( 4 c <br />PROJECT UESCRIPTIO ,_rG«?yt rJIwM ?/`.IF-rY?+-? /L. /J? w rLr?I?twti? s? fl ? t/ <br />CONTRACT NUMBER: ri 74e 1! /V67?.y Qst/.t.,at <br />FEDERAL-AID PROJECT NUMBER <br />TOTAL CONTRACT AMOUNT: S <br />FEDERAL SHARE (For local agotcy m complete) : S <br />BID DATE: 21?o%i <br />BIDDERS NAME: ? 1tr /Kac..t. ? ie???t+-fT.?A <br />ADVERTISED DBE CONTRACT AVwn ssaiLlTy ADVISORY Poem <br />NTRACT <br />ITEM NO. OF WORK AND DESCRIPTION <br />R SERVICES TO BE <br />UBCON'17tACTED OR MATERIALS <br />BE PROVIDED' BE Cot. No. <br />EXPIRATION <br />ATE E OF DHES ' <br />ust be eatified on the date bide <br />opoted -include DBE address <br />bane number • .t w R AMOUNT <br />BE' <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />PORTANT: Identify all DBE fittr® being parttetpat6tg is the project, re?rdkss of <br />'er. Names of the Fitat Tie DHE Subemtraeton and their respectlve item(s) of work <br />Total Claimed <br />$ ?? <br />fisted above should be cansistet; whets epplicsbk, with the names and itetrr of work in <br />'Last of Subeantrae0ws^ submitted with yaa bid. Reside copies of the DBEs' <br />uotcs, and if applicable, a copy of joint ve?ahtto agreernesta. pursuant m the <br />traetoo Lasting Law and the Special Pmvieiats. Parbcipaban . <br /> <br /> <br />? o <br />?o <br />1. Faster DBE pttra end subeontnetcrs ceetificsticn nuveber. Rime owttraeson shall <br />indicate all work m be performed by DBEs ineludnrg wank pofanted by its own <br />forces. <br />. If 100% of horn is not m ba performed or fianished by DBE, deetenlte eaeaet portion of <br />item m be perfarrrted a firrnished by DHE. <br />S <br />S <br />a <br />^Di <br />^ <br />ar a°"' of BIDDER <br /> <br />? / ?? ' ( y ?n? • ! 4 ?6' <br />. <br />ee <br />ex <br />oo <br />eadwo Busntess En <br />taged terprise (DBE), <br />of the Special Provisions <br />(construction contracts): m detvmme how m cant the putieipation of DBE firtrs. <br /> <br />Date , (Area Code) Tel. No. <br />l..oael Ageaey BIDDER -DBE Iofar>oseion (Rev S/01/06) <br />Dietnbutrao: (1) copy -Fax immediately m the Caltrans District Lain Assistance Engineo (DEAF) upon aware. <br />(2) Copy - Inehrde in award package m Caltr?ts Dirtrict Lceal Assistsn? <br />(3) Orlgtaal - Il.seal agesey glee <br />/ J <br />TO BE 1NCI..UDED IN BID PACKAGE <br />BP 22 of 31