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CITY OF SANTA ANA <br />PROPOSAL <br />PROJECT NO. 15-6830: Pedestrian Countdown Heads and Push Buttons <br />EXHIBIT 15-G CONSTRUCTION CONTRACT DBE COMMITMENT <br />1, Local Agency: City of Santa Ana <br />2. Contract DBE Goal: <br />3. Project Description: Replace exist no pedestrian heada to Countdown heads and push br tions <br />4. Project Location: Vadlaus Incations throuaho d the Cfy of Santa Ana <br />5. Bidder's Name: SIEMENS INDUSTRY, INC. <br />6. Prime Certified DBE: <br />❑ 7. Bid Amount: <br />8. Total Dollar Amount for ALL Subcontractors: 0 9. Total Number of ALL Subcontractors: 0 <br />10. Bid <br />Item <br />Number <br />11. Description of Work, Service, or Materials <br />Supplied <br />12. DBE <br />Certification <br />Number <br />13. DBE Contact Information <br />(Must be certified on the date bids are <br />opened) <br />14. DBE <br />Dollar <br />Amount <br />Local Agency to Complete this Section <br />$ 0 <br />21. Local Agency Contract Number: <br />22. Federal -Aid Project Number: HSIPL 5063(154) <br />15. TOTAL CLAIMED DBE PARTICIPATION <br />23. Bid Opening Date: <br />24. Contract Award Date: <br />IMPORTANT: Identify all DBE firms being claimed for credit, <br />regardless of tier. Names of the First Tier DBE <br />Subcontractors and their respective items) of work listed <br />above must be consistent, where applicable with the names <br />and items of the work in the "Subcontractor List" submitted <br />Local Agency certifies that all DBE certifications are valid and information on <br />with your bid. Written confirmation of each listed DBE is <br />this form is complete and accurate. <br />required. _ <br />o ei <br />16. Preparets.Siq9ture 11. Date <br />25. Local Agency Representative's Signature H. Date <br />STEVEN TEAL -Jj` _+'D j 6 <br />27. Local Aqency Representative's Name 28. Phone <br />s Name .� <br />1188`. 117,9. Phone <br />29. Local Agency Representative's Title <br />�Prepare <br />�j �� 7 �-X <br />��\C <br />20. Pre arer's Title <br />DISTRIBUTION: 1. Original - Lo cal Agency <br />2. Copy- Caltrans District Local Assistance Engineer (DLAE). Failure to submit to CLAP within 30 days <br />of contract execution may result in de -obligation of federal funds on contract. Include additional copy <br />with award package. <br />ADA Notice: For individuals with sensory disabilities, this document is available In alternate formats. For Information call (916) 654-6419 <br />or TDD (918) 654-3889 or write Records and Forms Management, 1129 N Street, MS -89, Sacramento, CA 95814. <br />BP -25 <br />