PTM GENERAL ENGINEERING SERVICIES INC. (2)

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M �, _7 1.-1 PROPOSAL PROJECT NO. 14-6799: Now Traffic Signal on Newhope Stand Camille St PROJECT NO. 14.6800: Traffic Signal Modification on Segrostrom Ave and Bear St INSTRUCTIONS - CONSTRUCTION CONTRACT DBE COMMITMENT CON MACTOIZ SECTIO 1, Local Agency - Enter the name ofthe local or regional agency that is hitting the contract. 2. Contract DBE Goal -linter the contract DBE good piaccivagc its it appears of the project advertisement. 3. Project Location - Fater the project location as itappoars, on the finkiect advertisement, 4. Project Description - Four the project description its it Appears on the firrrJect advertisement (Bridge Rehab, Seismic lWillb, Overlay, Widening. etc). i. Bidder's Name - Fluor the cmiffacuir's firan name 6, Prime Certified DBE - (1codc box if prime amftactor is a certified DBI 7. Bid Amount - Filter the Join[ contract bid dollar amount fir the prime contractor. 8. Total Dollar Amount for ALL Subcontractors — Enter the total dollar amount for all subcontracted contractors. SUM (DBFS + all Non -DBEs). Do not include the prime conuaQuor inimmatior in this count. 9. Total number of ALL subcontractors — floor 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 - ]-dater bid item number for work, services, or materials supplied to be provided. 11. Description of Work, Services, or Materials Supplied - Enter description ofwork, services, or materials to be provided. Indicate kill work to be perlin tried by DBEs including work performed by the prime corill-acton's rrwil forces, if the prime is a DBE It'] 00% ofthe item is not to be pci-fortired or famished by the DBP, describe the exact portion to he performed or J111 11;%lied by the DBK See LAYlvi Chnfact 9 to determine how to count Ite participation of'DBE firms. 12. DBE Certification Number - Enter the DBE's Certification Identification Number, Alt IMES must be certified on the date bids are opened, 13, DRE Contact information - Enter the tune, address, and phone number ofatl DBE subconbacted contractors. Also, enter the prime contractor's name and phone number, if the prime is a DBE, 14, DBE Dollar Amount - Fluor the Subcontracted dollar amount of the Work to be perfmined or service to be provided. Include the prime contractor if the prime is a DBF. See LAPNI Chirpier 9 fin how to count roll/partial participation, 15. Total Claimed DBE Participation - $: firmer the total dollar amounts entered in the -DBE Dollar Ainouirt"colmyrn, %: Enter the total DUE participation claimed ("Total Claimed D13F participation Dollars" divided by item "Bid Ammuna"), If the total 11% churned is less than item "Contract DBE Goal," an adequately documented Good Faith Effort (OFF) is inquired (see Exhibit IS- I[. DHE lufannafion - Good Faith Efforts of are LAPISh. 16, Preparers Signature - The person completing the DBE comillitracat firrm on behalf of tile coninctol Is firm must sign their Imine, 17. Date - Enter the date the DDE commitment foam is minted by the contractor's preparer. 18. Preparers Name - letter Ole name of the person preparing and signing the cordraI FAIL coraffiffitioart Form. 19. Phone - Erifici the area cooloc and phone number of the Person Sipling tilt' contractor's DDE commitment fount. 24). Preparer's Title - Enter the position/title offfic person simiag sipling contractor's DIIF conn uriont form. LOCAL A(JENCY SEC1 ION 21. Local Agency Contract Number - Fluor the Local Agency contract number or identifier. 22. Federal -Aid Project Number - Filter (lie Foderal-Aid Project Number, 23. Bid Opening Date - Enter the (title contract bids were opened, 24, Conti -act Award Date - Enter the date the contract was executed, 25. Locid Agency Reprosentativers Signature- T"he person coullpleting this Section of the ibrin IZ)r 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 - Filter The date the DBE corruinitiffent Rnniff is signed by the Local Agency Representative. 27. Local Agent), Representative's Name - Filter [lie name of [lie Local Agency Itepresidantive certifying the contractor's DHE commitment form. 28. Phone - Filter the area code and phone another of the person signing the contractor's DBE commitment Imill. 29. Local Agency Representative Title - klacir (lie local Ageticy, Ropiesentative certifying the contractor's D13F commitment form. BP -29