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Local Agency BIDDER-DBE (Construction Contracts)-Information <br />?he successful BIDDER must execute and return the LOCAL AGENCY BIDDER -DBE INFORMATION form, even if no DBE <br />articipation will be reported. <br />AGENCY: ?NT1? s-A\.1F\ `UY1aL \(l??j?,? LOCATION: <br />PROJECT DESCRIPTION: ?\?5?? `?'HQt!'-5 <br />CONTRACT NUMBER: \\80\y <br />FEDERAL-AID PROJECT NUMBER: <br />TOTAL CONTRACT AMOUNT: $ <br />FEDERAL SHARE (For local agency [o complete) : $ <br />BID DATE: Ld\ \ <br />BIDDER'S NAME: ??E ?S AS??T HC <br />ADVF.R TTSFD TIRE C`(INTR Af T AV ATT ARIT iTV AIIViS(lRV Perrenra or.? <br /> <br />ONTRACT <br />ITEM NO. <br />EM OF WORK AND DESCRIPTION <br />R SERVICES TO BE <br />SUBCONTRACTED OR MATERIALS <br />O BE P OVIDED' L1OQE <br />BE Cer[. No. - <br />ND EXPIRATION <br />ATE <br />NAME OF DBEs Ji.JD$E <br />(Must be certified on [he date bids <br />? re opened -include DBE address <br />nd hone number) <br />OLLAR AMOUNT <br />BE' <br /> <br />'??? ?? ?.?.51 IM4.7iN S? Cf?\N'. -_ \Z?? +.aP ? ?Z Qi "tom' <br />? 2ti0 J - 4icc->,rnc \Z?7 a - ?' ?? - <br />?°? \ \rJ0 ?Z' L? T -03\2?"7 p ?" OZ t-a00 - <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />PORTANT: Identify all DBE Frms being paz[icipa[ing in [he project, regardless of <br />ier. Names of the First Tier DBE Subcontractors and their respective item(s) of work <br />is[ed above should be consistent, where applicable, with the names and items of work in <br />he "Lis[ of Subcontractors" submitted with your bid. Provide copies of the DBEs' <br />uo[es, and if applicable, a copy of joint venture agreements. pursuant to [he <br />Subcontractors Listing Law and the Special Provisions. Total Claimed <br /> <br />Participation <br />? \?? ?Z? <br />? <br /> <br />a <br />?r3 ?' oJo <br />1. Enter DBE prime and subcontractors certification number. Prime contractors shall <br />indicate all work [o be performed by DBEs including work performed by its own - <br />forces. <br />If 100% of item is not [o be performed or furnished by DBE, describe exact potion of <br />item to be performed or furnished by DBE gnatu B R <br />_ $ 1i1 C?? <br />'l J <br />. <br />3. See Section "Disadvantaged Business Enterprise (DBE)," of the Special Provisions <br />(construction contracts); to determine how [o count [he participation of DBE firms. Dale (Area Code) Tel. No. <br /> <br />Local Agency t51UUCK - UtSC Intormanon (Kev ?/UIN6) <br />Dis[ribu[iom (1) Copy -Fax immediately to [he Caltrans Dis[ric[ Local Assistance Engineer (DLAE) upon award. <br />(2) Copy -Include in awazd package to Caltrans District Local Assistance <br />(3) Original -Local agency £ales <br />BP 24 of 37