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I <br /> I DISADVANTAGED BUSINESS ENTERPRISE WRITTEN CONFIRMATION <br /> N IRMATION DOCUMENT <br /> Mk <br /> � washington State Disadvantaged Business Enterprise (DBE) <br /> I <br /> �// Department of Transportation Written Confirmation Document <br /> See Contract Provisions: DBE Document Submittal Requirements <br /> I Disadvantaged Business Enterprise Participation <br /> THIS FORM SHALL ONLY BE SUBMITTED TO A DBE THAT IS LISTED ON THE CONTRACTOR'S <br /> DISADVANTAGED BUSINESS ENTERPRISE UTILIZATION CERTIFICATION. <br /> THE CONTRACTOR SHALL COMPLETE PART A PRIOR TO SENDING TO THE DBE. <br /> PART A:To be completed by_the bidder <br /> IThe entries below shall he consistent with what is shown on the Bidder's Disadvantaged Business Enterprise <br /> Utilization Certification.Failure to do so will result in Bid rejection. <br /> I <br /> Contract Title: 2023 Federal Overlays,City of Everett <br /> Bidder's Business Name: HM Pacific Northwest, Inc. <br /> I <br /> DBE's Business Name: Alpine Development, Inc. <br /> Description of DBE's Work: Iron Adjustments <br /> ' Dollar Amount to be Applied Towards DBE Goal: $7,425.00 <br /> Dollar Amount to be Subcontracted to DBE*: $ 17,500.00 <br /> 'Optional Field <br /> IPART B:7o be completed b y the Disadvantaged� Business Enterprise <br /> I As an authorized representative of the Disadvantaged Business Enterprise,I confirm that we have been <br /> contacted 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): Cheri VanderWel <br /> Signature: CC i'VALA� t/l(17C(Pc c cL€, , <br /> ITitle: President <br /> I Address: 20415 150th Ave SE Date: 04/04/2023 <br /> Monroe, WA 98272 <br /> I <br /> I <br /> DOT Form 422-031 <br /> IRevised 07/2016 <br /> I 2023 FEDERAL OVERLAY <br /> FEDERAL AIDM STBGUL-2715(011) <br /> WO#378B March 2,2023 130 <br /> IIProvided to Builders Exchange of WA, Inc. For usage Conditions Agreement see www.bxwa.com - Always Verify Scal <br />