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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 275-030-11 <br /> ANTICIPATED DBE PARTICIPATION STATEMENT EQUAL OPPORTUNITY OFFICE <br /> 03/11 <br /> Page 2 of B <br /> I . FINANCIAL PROJECT NO, 2. FAP NO. 3. CONTRACT NO. 4. COUNTY(IES) 5. DISTRICT <br /> r� M <br /> L3 t�- 1 - SS- o 1 � ► R�ae� �S, � �rc >1 <br /> 6. PRIME CONTRACTOR NAME 7. FEID NUMBER <br /> GppdSon QAv i� �� . � -2$ 7 2c�b5 <br /> _ . 8. CONTRACT DOLLAR AMOUNT 9 . REVISION ? 00 IF YES , REVISION NUMBER: <br /> % IS THE PRIME CONTRACTOR A FLORIDA 11 . IS THE WORK OFT IS CONTRACT <br /> CERTIFIED " DBE" ? (DISADVANTAGED NO CONSTRUCTIONOR MAINTENANCE ❑ ? <br /> BUSINESS ENTERPRISE) ❑ YES <br /> 12. ANTICIPATED DBE SUBCONTRACTS : <br /> PERCENT <br /> DBE SUBCONTRACTOR or SUPPLIER TYPE OF WORK/SPECIALTY DOLLAR AMOUNT CONTRACTF <br /> DOLLARS <br /> A Wt� rct�1V1 'RD�I'('�ro-�t{aL <br /> FRc& cr .) a 0lj �L Ig X915 . o v <br /> B <br /> C <br /> D <br /> E <br /> 17F TOTAL DOLLARS TO 12G TOTAL PERCENT <br /> DBE S OF CONTRACT <br /> $0 . 00 0.00 % <br /> 13. SUBMITTED BY id .DATE 15. TITLE OF SUBMI TER <br /> ?k ► � rFL =- U . P. (/1 A i es icll? I r <br /> 16. EMAIL ADDRESS OF SUBMITTER IT FAX NUMBER 18. PHONE NUMBER <br /> 321 �631 =oy�t1 3Z� -�� t -5523 <br /> NOTE: THIS INFORMATION IS USED TO TRACK AND REPORT ANTICIPATED DBE PARTICIPATION IN ALL STATE AND FEDERALLY <br /> FUNDED FOOT CONTRACTS . THE ANTICIPATED DBE AMOUNT IS VOLUNTARY AND WILL NOT BECOME A PART OF <br /> THE <br /> CONTRACTUAL TERMS . THIS FORM MUST BE SUBMITTED AT THE PRE CONSTRUCTION OR PRE WORK CONFERENCE. FOOT STAFF <br /> FORWARDS THE FORM TO THE EQUAL OPPORTUNITY OFFICE, <br /> THE FOLLOWING SECTIONS ARE FOR FOOT USE <br /> 19 .PROCESSED BY 20. DATE TO EO OFFICE 21 . LETTING DATE 22, EXECUTED DATE 23. PRECON CONF DATE <br /> DIST <br /> 24 .SUBMITTED TO EO ❑ FAX ❑ EMAIL <br /> BY ❑ SHARED FOLDER <br /> EO 25 .INCLUDED IN QBE PARTICIPATION REPORT OF M/D/Y <br /> OFC <br /> 470 - 2 <br />