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Local Agency BIDDER-DBE (Construction Contracts)-Information <br />The successful BIDDER must execute and return the LOCAL AGENCY BIDDER -DBE INFORMATION form, even if no DBE <br />participation will be reported. <br />AGENCY:- 7-?KY?-???'-?--? ?'']?S LOCATION: A <br />PROJECT DESCRIPTION: Rosita Park <br />CONTRACT NUMBER:- \ S <br />FEDERAL-AID PROJECT NUMB R: \? 7 S?1J <br />TOTAL CONTRACT AMOUNT: $ <br />FEDERAL SHARE (For 1 cal a ency to complete) : $ <br />BID DATE: i'1 9u?? O\? <br />BIDDER'S NAM- E? -?LSp n[? S7vaq rT" <br />w n IIiC l1DV De?ru??n ?o? <br />ONTRACT <br />ITEM NO. EM OF WORK AND DESCRIl'TION <br />R SERVICES TO BE <br />SUBCONTRACTED OR MATERIALS <br />O BE PROVIDED ? BE Cert. No. <br />ND EXPIRATION <br />ATE AME OF DBEs ? <br />Mus[ be certified on the date bids <br />re opened -include DBE address <br />and hone number) OLLAR AMOUNT <br />BE ' <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />PORTANT: Identify all DBE firms being participating in [he project, regardless of <br />First Tier DBE Subcontractors and their respective item(s) of work <br />f [h <br />i <br />N Total Claimed <br />ames o <br />e <br />er. <br />is[ed above should be consistent, where applicable, with the names and items of work in <br />he "List of Subcontractors" submitted with your bid. Provide copies of the DBEs' <br />uo[es, and if applicable, a copy of joint venture agreements. pursuant [o [he <br />Subcontractors Listing Law and the Special Provisions. pazticipa[ion <br /> <br /> <br /> <br />fp <br />1. Enter DBE prime and subcontractors certiF cation number. Prime contractors shall <br />DBEs including work performed by its own <br />erformed b <br />ll work [o be <br />di <br />t <br />i <br />? <br />y <br />p <br />ca <br />e a <br />n <br />forces. <br />Tf ]00% of item is not [o be performed or famished by DBE, describe exact portion of <br />nished b <br />DBE <br />d <br />fu <br />b <br />f <br />i Si na[ e D <br />t--i Lt ` _ 4 `ur•1 <br />I?J`J <br />y <br />. <br />orme <br />or <br />r <br />tem [o <br />e per <br />. See Section "Disadvantaged Business Enterprise (DBE)," of the Special Provisions <br />(construction contracts); [o determine how [o count the participation of DBE Firms. Date (Area Code) Tel. No. <br /> <br />?7y_?_ ? /t ???,`T ??C <br /> <br />...,.,... r.d,..._? . <br />Distribution: (1) Copy -Fax immediately [o [he Caltrans Dis[ric[ Local Assistance Engineer (DEAF) upon award. <br />(2) Copy -Include in awazd package [o Ca][rans District Local Assistance <br />(3) Original -Local agency Files <br />BP 24 of 37