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I <br /> Washington State Disadvantaged Business Enterprise (DBE) <br /> IWI Department of Transportation Written Confirmation Document <br /> See Contract Provisions': DBE Document S'ubrni.tta.l Requirements <br /> I <br /> Disadvantaged Business Enterprise Participation <br /> THIS FORM SHALL ONLY BE SUBMITTED TO A DBE THAT IS LISTED ON THE CONTRACTOR'S <br /> IDISADVANTAGED BUSINESS ENTERPRISE UTILIZATION CERTIFICATLON. <br /> THE CONTRACTOR SHALL COMPLETE PART A PRIOR TO SENDING TO THE DBE. <br /> IPART A: To be completed by the bidder <br /> The entries below shall be consistent with what is shown on the Bidder's Disadvantaged Business Enterprise <br /> I <br /> Utilization Certification. Failure to do so will result in Bid rejection. <br /> Contract Title: Fleming Bicycle Corridor <br /> ' <br /> Bidder's Business Name: Always Active Services LLC <br /> • <br /> I DBE's Business Name: Hughes Group <br /> Description of DBE's Work: Traffic Control, Flagging <br /> I Dollar Amount to be Applied Towards DBE Goal: $40,000 <br /> 1 Dollar Amount to be Subcontracted to DBE*: <br /> 'Optional Field <br /> IPART B: To be completed by the Disadvantaged Business Enterprise <br /> As an authorized representative of the Disadvantaged Business Enterprise, I confirm that we have been <br /> Icontacted by the Bidder with regard to the referenced project for the purpose of perfonning the Work described <br /> above. If the Bidder is awarded the Contract, we will enter into an agreement with the Bidder to participate in <br /> the project consistent with the information provided in Part A of this form. <br /> IName (printed): kk4-'14 ('51 640 U& ` <br /> Signature: CL—h.4 -- a6 666. <br /> ii Title: ' /KL4A/L a <br /> 11 <br /> Address: Date: /f"/ �� 2 Z <br /> d 3 7 0 / 5 . 44 k)f-t,�'Ce s�. <br /> I aco,v)c , WA- , 98107 <br /> I <br /> I <br /> IDOT Form A22-031 Page 15 of 30 <br /> Revised 07/2016 <br />