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Itat Disadvantaged Business Enterprise (DBE) <br /> Department of Transportation Written Confirmation Document t <br /> 1 See Contract Provisions: DBE Doctnrreni Submittal Requirements <br /> Disadvantaged Business Enterprise Condition ofAivard Participation <br /> I <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 /> I <br /> PART A: To be completed by the bidder <br /> I <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 /> I <br /> Contract Title: 6,' w,f .e..- ?4-i. GJ,c,__. f�,.,,,. Po 342.8 <br /> Bidder's Business Name: ,-;;,;!J ��,,,(Ae.; y,.G, <br /> 1 DBE's Business Name: 14.,,,o 5to� ;..-,'1r�S 2-2-C <br /> Description of DBE's Work: „ily, , $75,.i--G -Pel,. 5.S..A5 ,::::.4,. .., noo -zi.��/) <br /> IAmount to be Applied Towards DBE Goal: Li/0 orr-z, <br /> 1 Amount to be Subcontracted to DBE*: <br /> 'Optional Field <br /> I <br /> PART 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 /> contacted by the Bidder with regard to the referenced project for the purpose of performing the Work described <br /> I <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 /> Pehv' <br /> -Mame (printed): (,7 - <br /> I Signature: WIV C,= <br /> v r � � <br /> Title: GAh' %/1' <br /> IAddress: g 3 i /r` Date: i /1/ 17 <br /> P /Meek Eia gni <br /> 1 <br /> I <br /> I <br /> DOT Form 422-031 <br /> Revised 07/2016 <br /> Page 167 Disadvantage Business Enterprise(DBE)Written Confirmation Document <br /> 'ovided-to Builders Exchange of WA, inc.For usage Conditions Agreement see www.bxwa:com=Always Verify Scale __ <br />