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Attachment One, page 3 of 4 <br /> Disadvantaged Business Enterprise (DBE) <br /> WashDepartment <br /> State Written Confirmation Document <br /> pepaxfinent of Transportation <br /> See Contract Provisions: DBE Document Submittal Requirements <br /> Disadvantaged Business Enterprise Condition ofAwaid 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 COMPT.PTE PART A PRIOR TO SENDING TO THE DBE. <br /> PART 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 /> Utilization Certification.Failure to do so will result in Bid rejection. <br /> Contract Title: That Pt{ (2.0AbwAi /c,9 Vi/Der. ,q- �+M•pr26 v lvtun-'T3 <br /> Bidder's Business Name: A(i✓ 5Tz)/1'.A-•c—cPce--r .L) ) e—. <br /> DBE's Business Name: WL T1 xN ('D5M ©o 1 0C"Z,' <br /> Description of DBE's Work: E 01' 772÷6.Prvr, <br /> oObS� .5" 11.75 <br /> � r � <br /> Amount to be Applied Towards DBE Goal: <br /> Amount to be Subcontracted to DBE's`: <br /> `Optional Field <br /> PART B:To be completed by the Disadvantaged Business Enterprise <br /> As an authorized representative of the Disadvantaged Business Enterprise,I confute that we have been <br /> contacted by the Bidder with regard to the referenced project for the purpose of performing the Work described <br /> above.If the Bidder is awarded the Contract,we will enter into an agreement with the Bidder to participate <br /> in the project consistent with the information provided in the Bidder's Disadvantaged Business Enterprise <br /> Utilization Certification. <br /> Name(printed): Bruno Padilla <br /> Signature: c ' l+ <br /> Title: President, Electric West__ <br /> Address: Date: 911/16 <br /> Electric West <br /> 817 N.6th St.Ste B <br /> Mt Vernon,Wa.98273 <br /> DOTForm 422-039 <br /> O n.Jn nd!P]1'Al <br />