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EXHIBIT 15 -G LOCAL AGENCY BIDDER DBE COMMITMENT (CONSTRUCTION CONTRACTS) <br />NOTE: PLEASE REFER TO INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM <br />LOCAL AGENCY LOCATION: PROJECT: 12 -6758: TRAFFIC SIGNAL <br />INSTALLATION ON FAIRVEIW ST & EDNA DR <br />PROJECT DESCRIPTION: <br />TOTAL CONTRACT AMOUNT: $ <br />BID DATE: <br />BIDDER'S NAME: Ie <br />CONTRACT DBE GOAL: O <br />CONTRACT ITEM <br />O. <br />ITEM OF WORK AND DESCRIPTION OR <br />SERVICES TO BE SUBCONTRACTED <br />R MATERIALS TO BE PROVIDED (or <br />contracted if the bidder is a DBE) <br />DBE CERT NO. <br />AND EXPIRATION <br />DATE <br />NAME OF EACH DBE <br />(Must be certified on the date bids <br />are opened - include DBE address <br />and phone number) <br />DOLLAR AMOUNT <br />DBE <br />I-Z <br />9011 <br />T6 <br />6 <br />Is <br />For Local Agency to Complete: <br />Local Agency Contract Number: <br />Federal -aid Project Number: <br />Federal Share: $35,030 <br />Contract Award Date: <br />Local Agency certifies that all DBE certifications have been verified and <br />information is complete and accurate. <br />Print Name Signature Date <br />Local Agency Representative <br />(Area Code) Telephone Number: <br />Total Claimed DBE <br />Participation <br />$ 33"9q<, '37 <br />% <br />S' a of Bidder <br />S77,,,,�� <br />-�tJw <br />Date (Area Code) Tel. No. <br />Person to Contact (Please Type or Print) <br />tid1 ��' W ) <br />Local Agency Bt DB o tment onstruction Contracts <br />(Rev 6/26/09) <br />Distribution: (1) Copy - Fax or scan a copy to the Caltrans District Local Assistance Engineer (DLAE) within 30 days of contract execution. Failure to <br />send a copy to the DLAE within 30 days of contract execution may result in de- obligation of funds for this project. <br />(2) Copy - Include in award package to Caltrans District Local Assistance <br />(3) Original - Local agency files <br />TO BE INCLUDED IN BID PACKAGE <br />BP 21 of 30 <br />