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I <br /> � Washington State Disadvanta ed Business <br /> 111 Department of Transportation 9 <br /> Enterprise Utilization Certification <br /> To be eligible for Award of this Contract the Bidder shall fill out and submit, as a supplement to its sealed Bid Proposal, <br /> Pa Disadvantaged Business Enterprise (DBE) Utilization Certification.The Contracting Agency shall consider as non- <br /> responsive and shall reject any Bid Proposal that does not contain a DBE Utilization Certification which properly <br /> demonstrates that the Bidder will meet the DBE participation requirements in one of the manners provided for in the <br /> proposed Contract. Refer to the instructions on Page 2 when filling out this form or the Bid may be rejected.An <br /> I <br /> example form has been provided on Page 3.The successful Bidder's DBE Utilization Certification shall be deemed a <br /> part of the resulting Contract. <br /> Box 1: HM Pacific Northwest, Inc. certifies that the DBE firms listed below have been contacted <br /> regarding participation on this project. If this Bidder is successful on this project and is awarded the Contract, it shall <br /> assure that subcontracts or supply agreements are executed with named DBEs. (If necessary, use additional sheets.) <br /> Box 2: STBGUL-2715(011) (WO#3788) -2023 Federal Overlay, City of Everett <br /> IColumn 1 Column 2 Column 3 Column 4 Column 5 <br /> Name of DBE Project Role Description of Work Dollar Amount Dollar Amount <br /> 111 (See instructions) (See instructions) (See Instructions) Subcontracted to be Applied <br /> to DBE Towards Goal <br /> (See instructions) (See instructions) <br /> G&G,Inc. Electrical Subcontractor Vehicle Detection Loops&Traffic Signal System Install $226,800.00 $226,800.00 <br /> Alpine Development,Inc. Iron Adjustments Utility Cover Adjustments $17,500.00 $7,425.00 <br /> Subcontractor <br /> I <br /> I <br /> I <br /> I <br /> I <br /> I <br /> IDisadvantaged Business Enterprise $217,528.83 Total DBE Commitment Dollar Amount $234,225.00 <br /> Condition of Award Contract Goal Box 3 Box 4 <br /> 5 nBy checking Box 5 the Bidder is stating that their attempts to solicit sufficient DBE participation to meet the COA Contract goal <br /> I has peen unsuccessful and good faith effort will be submitted in accordance with Section 1-02.9 of the Contract <br /> DOT Form 272-056 Revised 03/2018 <br /> P2023 FEDERAL OVERLAY C <br /> FEDERAL AID#STBGUL-2715(011) <br /> WO#3788 March 2,2023 127 <br />