25L - AGMT - ON-CALL RIGHT OF WAY SRVS

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Local Assistance Procedures Manual EXHIBIT 10 -01 Consultant Proposal DBE Commitment INSTRUCTIONS - CONSULTANT PROPOSAL DBE COMMITMENT Consultant Section The Consultant shall: 1. Local Agency Name -Enter the name of the local or regional agency that is funding the contract. 2. Project Location -Enter the Project location as it appears on the project advertisement. 3. Project Description -Enter the project description as it appears on the project advertisement (Bridge Rehab, Seismic Rehab, Overlay, Widening, etc.). 4. Consultant Name -Enter the consultant's firm name. S. Contract DBE Goal %- Enter the contract DBE goal percentage, as it was reported on the Exhibit 104 Notice to Proposers DBE Information form. See LAPM Chapter 10. 6. Description of Services to he Provided - Enter item of work description of services to be provided. Indicate all work to be performed by DBEs including work performed by the prime consultant's own forces, if the prime is a DBE. If 100% of the item is not to be performed or furnished by the DBE, describe the exact portion to be performed or furnished by the DBE. See LAPM Chapter 9 to determine how to count the participation of DBE firms. 7, DBE Firm Contact Information - Enter the name and telephone number of all DBE subcontracted consultants. Also, enter the Prime consultant's name and telephone number, if the prime is a DBE. 8. DBE Cart. Number -Enter the DBEs Certification Identification Number. All DBEs must be certified on the date bids ere opened, (DBE subcontracted consultants should notify the prime consultant in writing with the date of the decertification if their status should change during the course of the contract.) 9. DBE % - Percent participation of work to be performed or service provided by a DBE. Include the prime consultant if the prime is a DBE. See LAPM Chapter 9 for how to count frill /partial participation. 10. Total % Claimed — Enter the total DBE participation claimed. If the Total % Claimed is less than item °6. Contract DBE Goal ", an adequately documented Good Faith Effort (GFE) is required (see Exhibit 15 -H DBE Information - Good Faith Efforts of the LAPM). 11. Preparer's Signature —The person completing this section of the form for the consultant's firm must sign their name. 12. Preparer's Name (Print) — Clearly enter the time of the person signing this section of the form for the consultant 13. Preparer's Title -Enter the posidon/title of the person signing this section of the form for the consultant. 14. Date - Enter the date this section of the form is signed by the preparer. 15. (Area Code) Tel. No. - Enter the area code and telephone number of the person signing this section of the form for the consultant, Local Azenev Section: The Local Agency representative shall: 16. Local Agency Contract Number- Enter the Local Agency Contract Number, 17. Federal -Aid Project Number - Enter the Federal -Aid Project Number. 18. Contract Execution Date - Enter date the contract was executed and Notice to Proceed issued. See LAPM Chapter 10, page 23. 19. Local Agency Representative Name (Print) - Clearly enter the name of the person completing this section. 20. Local Agency Representative Signature -The person completing this section of the form for the Local Agency must sign their name to certify that the information in this and the Consultant Section of this form is complete and accurate. 21. Dote - Enter the date the Local Agency Representative signs the form. 22. Local Agency Representative Title -Enter the posttionititle of the person signing this section of the form. 23. (Area Code) Tel. No. - Enter the area code and telephone number of the Local Agency representative signing this section of the form. LPP 13 -01 25L -63 Page 2 of 2 May 8, 2013