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CITY OF SANTA ANA PROPOSAL PROJECT NO.: 15 -6834 TRAFFIC SIGNAL MODIFICATIONS: 17TH STREET AT ENGLISH STREET, MACARTHUR BOULEVARD AT PLAZA DRIVE, EDINGER AVENUE AT SULLIVAN STREET, WESTMINSTER AVENUE AT CLINTON STREET FEDERAL PROJECT NO: HSIPL 5063(156) INSTRUCTIONS — CONSTRUCTION CONTRACT DBE COMMITMENT CONTRACTOR SECTION 1, Local Agency - Enter the name of the local or regional agency that is funding the contract. 2. Contract DBE Goal - Enter the contract DBE goal percentage as it appears on the project advertisement. 3, Project Location - Enter the project location as It appears on the project advertisement, 4. Project Description - Enter the project description as It appears on the project advertisement (Bridge Rehab, Seismic Rehab, Overlay, Widening, etc). - 5. Bidder's Name - Enter the contractor's firm name. 6. Prime Certified DBE - Check box if prime contractor is a certified DBE. 7. Bid Amount - Enter the total contract bid dollar amount for the prime contractor. 8. Total Dollar Amount for ALL Subcontractors — Enter the total dollar amonmt'for all subcontracted contractors. SUM = (,DBEs + all Non. DBEs). Do not include the prime contractor information in this count, 9. Total number of ALL subcontractors — Enter the total number of all subcontracted contractors. SUM = (DBEs + all Non- DBEs). Do not include the prime contractor information in this count. _ 10. Bid Item Number - Enter bid item number for work, services, or materials supplied to be provided. 11. Description of Work, Services, or nNlaterials Supplied - Enter description of week, services, or materials to be provided. Indicate all work to be performed by DBEs Inehiding work performed by the prime contractor's own 'forces, if the prince 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. 12, DBE Certification Nmnber- Enter the DBE's Certification Identi'ficat'ion Number, All DBEs must be certified on the date bids are opened. 13. DBE Contact Information - Enter the name, address, and phone number of all DBE subcontracted contractors. Also, enter the prime coca actoCs name and phone number, if the prhue is a DBE, 14, DBE Dollar Amount - Enter the subcontracted dollar amount of the work to be performed or service to be provided Include the prime contractor if the prime is a DBE. Sea LAPM Chapter 9 for how to count fall /partial participation. 15. Total Claimed DBE Participation - $: Enter the t'ot'al dollar amounts entered in the 'IDBE Dollar Amount" column. %: Enter the total DBE participation claimed ("'total Claimed DBE Participation Dollars" divided by Item `Bid Amount"). If the total %claimed is less than item "Contract DBE Goal," an adequately documented Good Faith Effort (GPE) is required (sac Exhibit 15 -H DBE Inc "ormation - Good Eaith Efforts of tha LAPM). 16, Preparer's Signature - The person completing the DBE commitment' form on behalf of the contractor's firm must sign their name. 17, Date - Enter the date the DBE commitment form Is signed by the contractor's praparer. 18. Preparer's Name - Enter the name of the person preparing and signing the contractor's DBE commitment form, 19. Phone - Enter the area code and phone number of the persoa signing the contractor's DBE commitment form. 20. Preparer's 'Title - Enter the posjllon /title of the person signing the contractor's DBE commitment form, LOCAL AGENCY SECTION 21. Local Agency Contract Number - Enter the Local Agency contract number or identifier. - 22. Federal -Aid Project Number - Enter the Federal -Aid Project Number. 23, ,Bid Opening Date - Enter the date contract bids were opened, 24. Contract Award Date -- Enter the dale the contract was executed. 25. Local Agency Representative's 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 Contractor Section of this form Is complete and accurate. 26. Date - Enter file data the DBE commitment form is signed by the Local Agency Repiesentahve. 27, Local Agency Representative's Name - Enter the name of the Local Agency Representative certifying the contractor's DBE commitment form. 28. Phone - En ter the area code and phone number of the person signing the contractor's DBE commitment form. - 29. Local Agency Representative Title - Enter the positionhitle of the Local Agency Representative certifying the contractor's DBE commitment'fm•m. P -28 of P -40 20D-43