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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:_ <br />PROJECT DESCRIPTION: <br />CONTRACT NUMBER:_ <br />FEDERAL -AID PROJECT NUMBER: <br />TOTAL CONTRACT AMOUNT: $ <br />FEDERAL SHARE (For local a to complete) : $ <br />BID DATE: <br />BIDDER'S NAME: (i ! )Q CLIYA <br />ADVERTISED DEE CONTRACT AVAILABILITY ADVI <br />ee: <br />LOCATION: <br />CONTRACT <br />ITEM NO. <br />ITEM OF WORK AND DESCRIPTION <br />OR SERVICES TO BE <br />SUBCONTRACTED OR MATERIALS <br />O BE PROVIDED '- <br />DBE Cert. No. <br />AND EXPIRATION <br />DATE <br />NAME OF DBEs' <br />Must be certified on the date bids <br />are opened - include DBE address <br />nd phone number) <br />DOLLAR AMOUNT <br />DBE' <br />SG <br />, <br />✓r i - I <br />J d'z1-o <br />IMPORTANT: Identify all DBE firms being participating in the project, regardless of <br />tier. Names of the First Tier DBE Subcontractors and their respective item(s) of work <br />listed 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 />uotes, and if applicable, a copy of joint venture agreements. pursuant to the <br />Subcontractors Listing Law and the Special Provisions. <br />I . Enter DBE prime and subcontractors certification number. Prime contractors shall <br />indicate all work to be performed by DBEs including work performed by its own <br />forces. <br />If 100% of item is not to be performed or famished by DBE, describe exact portion of <br />item to be performed or furnished by DBE. <br />3. See Section "Disadvantaged Business Enterprise (DBE)," of the Special Provisions <br />(construction contracts), to determine how to count the participation of DBE firms. <br />Total Claimed�;LtG., <br />participation <br />— �— <br />_7 t <br />Signature of BID <br />/ <br />Date 2 / 1 / 1 (A a Code) Tel. No. <br />Local Agency BIDDER - DBE Information ( ev 5/ I/ 6) <br />Distribution: (1) Copy -Fax immediately to the Caltrans District Local Assistance Engineer (DLAE) upon award. <br />(2) Copy - Include in award package to Caltrans District Local Assistance <br />(3) Original — Local agency Tiles <br />TO BE INCLUDED IN BID PACKAGE <br />BP 20 of 28 <br />