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Local Agency BIDDER-DBE (Construction Contracts)-Information <br />e successful BIDDER must execute and return the LOCAL AGENCY BIDDER -DBE INFORMATION form, even if no DBE <br />articipation will be reported. <br />AGENCY:- ?.13t4?.l? ti?C7'1?.'] LOCATION: S ?? <br />PROJECT DESCRIPTION: Southwest Senior Center <br />CONTRACT NUMBER:- \ O _ O <br />FEDERAL-AID PROJECT NUMBER: ?OlS(o?? <br />TOTAL CONTRACT AMOUNT: $ <br />FEDERAL SHARE (For 1 cal a$ency,to complete) : $ <br />BID DATE: ?-/(? -L?t? <br />BIDDER'S NAME: ? S-?1trhC <br />AD VERTISRD DRE CONTRACT AV AiLAR7iJTY ADVISORY Perr .nta net <br />ONTRACT <br />ITEM NO. ITEM OF WORK AND DESCRIPTION <br />R SERVICES TO BE <br />SUBCONTRACTED OR MATERIALS <br />O BE PROVIDED ? BE Cert. No. <br />D EXPIRATION <br />ATE AME OF DBEs ` <br />(Must be certified on the date bids <br />aze opened -include DBE address <br />nd hone number) OLLAR AMOUNT <br />IIE 3 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />PORTANT: Identify all DBE firms being participating in [he project, regazdless of <br />ier. Names of the First Tier DHE Subcontractors and their respective item(s) of work Total Claimed <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 join[ venture agreements. pursuant to the <br />ubcontrac[ors Listing Law and [he Special Provisions. Participation <br /> <br /> <br />,? <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 />- <br />forces. <br />If 100% of item is no[ to be performed or furnished by DBE, describe exact portion of <br />item [o be performed or furnished by DBE. gnatu DE <br />?t <br />- is-?-?? t L L?, <br /> <br />3. See Section "Disadvantaged Business Enterprise (DBE)," of the Special Provisions <br />(cons[mction contracts); [o determine how [o count [he participation of DBE firms. Date (Area Code) Tel. No. <br />p <br />?QNS m?Ct'?l?C <br /> <br />Local Agency t31UUtK - U13C tntormanon (Kev ?/Ul/U6) <br />Distribution: (1) Copy -Fax immediately to [he Cal[rans Dis[ric[ Local Assistance Engineer (DEAF) upon award. <br />(2) Copy -Include in award pacKage [o Caltrans District Local Assistance <br />(3) Original -Local agency files <br />BP 27 of 37