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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: PROTECT: 12 -6759: TRAFFIC SIGNAL <br />PROJECT DES MODIFICATION ON McFADDEN AVE & EUCLID ST <br />CRIPTION: <br />TOTAL CONTRACT AMOUNT: $ <br />BID DATE: <br />BIDDER'S NAME: ' <br />O <br />CONTRACT DBE GOAL: <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 />Z - RL <br />3 $y .3 <br />'Wofm 1-20 <br />For Local Agency to Complete: <br />Local Agency Contract Number: <br />Federal -aid Project Number: <br />Federal Share: $30,050 <br />Contract Award Date: <br />Local Agency certifies that all DBE certifications have been verified and <br />information is complete and accurate. <br />Print Name Signature Date <br />Local Agency Representative <br />(Area Code) Telephone Number: <br />Total Claimed DBE <br />Participation <br />� <br />$ 3� t �f3. 3 <br />8 % <br />re of Bidder <br />a <br />S <br />a e (Area Code) Tel. No. <br />11 W �1 �M; �^ <br />Person to Contact ' � 1 (Please Type or Pr' t) <br />1 `' J � 7n— �' <br />Local Agency er D Commitment (Construction 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 22 of 30 <br />