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Item 21 - Agreement for Willits Street Safe Routes to School Education Program
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Item 21 - Agreement for Willits Street Safe Routes to School Education Program
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8/14/2023 3:08:26 PM
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8/14/2023 3:07:55 PM
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City Clerk
Doc Type
Agenda Packet
Agency
Clerk of the Council
Item #
21
Date
9/6/2022
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<br />Local Assistance Procedures Manual Exhibit 10-O2 <br />Consultant Contract DBE CommitmentEXHIBIT 1 <br />EXHIBIT 10-O2 CONSULTANT CONTRACT DBE COMMITMENT <br />1. Local Agency:2. Contract DBE Goal: <br />3. Project Description: <br />4. Project Location: <br />5. Consultant's Name:6. Prime Certified DBE: 7. Total Contract Award Amount: <br />8. Total Dollar Amount for ALL Subconsultants:9. Total Number of ALL Subconsultants: <br />11. DBE <br />Certification <br />Number <br />13. DBE <br />Dollar <br />Amount <br />10. Description of Work, Service, or Materials <br />Supplied 12. DBE Contact Information <br />Local Agency to Complete this Section <br />$20. Local Agency Contract <br />14. TOTAL CLAIMED DBE PARTICIPATION <br />21. Federal-Aid Project Number: <br />%22. Contract Execution <br />Date: <br />Local Agency certifies that all DBE certifications are valid and information on <br />this form is complete and accurate. <br />IMPORTANT: Identify all DBE firms being claimed for credit, <br />regardless of tier. Written confirmation of each listed DBE is <br />required. <br />23. Local Agency Representative's Signature <br />25. Local Agency Representative's Name <br />24. Date 15. Preparer's Signature <br />17. Preparer's Name <br />19. Preparer's Title <br />16. Date <br />26. Phone 18. Phone <br />27. Local Agency Representative's Title <br />DISTRIBUTION: 1. Original – Local Agency <br />2. Copy – Caltrans District Local Assistance Engineer (DLAE). Failure to submit to DLAE within 30 days of contract <br />execution may result in de-obligation of federal funds on contract. <br />ADA Notice: For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654- <br />3880 or write Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814. <br />Page 1 of 2 <br />July 23, 2015
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