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HomeMy WebLinkAbout05) Fee Justifaction Reportfl~(~3 ~. • FEE JUSTIFICATION REPORT CONSTRUCTION ENGINEERING SERVICES JEFFERSONVILLE, INDIANA ALLISON LANE AND SEMINOLE DRIVE TRAFFIC SIGNAL INSTALLATION PROJECT NO. 9910(029) DES. NO. 0400427 Submitted by: JACOBI, TOOMBS AND LANZ, INC. CONSULTING ENGINEERS 120 BELL AVENUE CLARKSVILLE, IN 47129 812/288-6646 812/288-6656 FAX February, 2005 'J • • A. DESCRIPTION OF PROPOSED PROJECT The project consists of improving the intersection of Allison Lane and Seminole Drive by reconstructing the street approaches, concrete sidewalks, and installing a new traffic signal system. This project will also improve traffic flow in and out of Jeffersonville High School. Only part-time Construction Engineering Services are deemed required for this project. 5. Provide any other miscellaneous services when required by the City and the Indiana Department of Transportation. . B. DESCRII'TION OF ANTICIPATED WORK ELEMENTS Jacobi, Toombs and Lanz, Inc. will perform the following tasks to provide Construction Engineering Services for this project: 1. Attend pre-construction conferences as required by Jeffersonville and the Indiana Department of Transportation and coordinate the scheduled job progress with the Contractor and Federal, State and Local Government agencies. 2. Provide a part time onsite Project Representative, INDOT Certified, who will be responsible for keeping daily construction records, conducting all the required onsite sampling and testing of materials, and ascertaining that the project is being constructed in accordance with construction plans and specifications. 3. Provide specialty inspectors during concrete hatching operations, installation of • bituminous courses, and any other operations as required by the Indiana Department of Transportation. 4. Provide a Project Manager-Coordinating Engineer, who will be responsible for overseeing the overall inspection of the project, supervise inspectors and the project representative, coordinating meetings and onsite inspections with representatives of the FhWA and INDOT and providing all the reports, final estimates and asbuilt plans that may be required. 5. Provide any other miscellaneous services when required by the City and the Indiana Department of Transportation. :~ P.nA f ~:I,Lvunsfort i I r• ~-••• I ., (' Is k Denlen Spr, 4l. Three Rivers Meudlin (.,l aua, I in .. •a,,.r.. I,, , a1"I•.,.+ .dtr•y' 1~~y, or ~ &idP,lnanro cl Dowoglac 1 g, C' Idwctler.dl. u) rp. b,~,,,.~ •. 1 • ('rnevn MaYwnp ~C~~et~„y~ ^r/, ~/ OERn1EN „O. 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P W.Laloyelle ~• ~--- -~- Maahews Y M,n,ler U Pa ton Rankin I'too eslon " Dayt n r'Rnssvilh: ~.~'r----t•Lr„u,.,1 o glllunhnp ]Ar fl Reravery- ~ 1 `~ '' „~ Nu!.•.J,IIL'n WARREN Lela elle(~ ,.M„r,,,.,, SL gsmlh•O OYIIIdIall (OSuaundmlle ~,I,,ImI n r-'._-- OSUFI nr Or•,.,I, Ronloul I ~ Rcdkc ,,.~.~.,,,~'~ ft,•Ilcl,•~~I'~" vElaMtLION , r Y fI Ima,r, ) In ll r1 TIPPt'_CANOE - _ 1 IIriON ~M wt11KOt/ 1 O DELA Irt~--- nl(,d ev,l CIAItKF_ I ,('1, ,t•, W.) ~I.~,I, Wdhatnsparl ~ (ronkiort t:aslon nwany g tr Gdlnld fhdnmat O.m /) .!). ~. o) wnR[.. Vm,adfrs $idne ._ <a•Alrr, wl.bann„o mAlrilvldna Mn,n,,, Ansrmia Y c11A , A,Ilim Slackwell CLINION Tipton Hwood i, Ig;rne L)mon c, t;, - MrAi,~il ~ 1 rn,rl `~~ Cnllaa Kirklin r]MUflCle f. r l(~mlann Cif a; ~ ,,,•. „_ 'I •~1 Donville_ o Auanla I,an~lon. ~rarse, Y ~ Piqua Invh•~ 'tl,P "I' fnvmglon ollnArn~ ~ g,ra,ha'~ 1 Yn,sl,iwnl) I;dr .~. Rtndlnld (ri1 O ~., i11,V.• r]ncxar Anderson. t~)• n• Kmsy na Uahuglaa fl ~;he1,,l,,n• f.x:mn'~ IOllaltudlr. WII1Che516r .IQ Cum~4'run MIAMI ~i rjJS~' llar ^..od r, C/ p i O Ib nnlnwu td w ' 1 .„vn ~:/ Yteds •~hmg' 'l Wavn,•In..n ge ,and4.~,. n heslerheld RANfIOIF'll I „Ihn•.,,a~~l,~~,r ,:. . n Urbana \nlpP1 u 0 ' / ' Lebanon' Noblesville, larrdp p n Greenville r7 ~ ,Lr,y 111 1 r « „u's Crawlordsvillc a ~t• wmlas r. .tp. Miler"*'~,` Lynn • . rna r Inn r „ t_.. ' u , r U ralnn dr y roan MrN r 'G. W t'.resllawn HENRY - O ~rn Mdlnn I,pl, I.,ly ( '•, r, '1 •••1, ~, ~ I( IwONI- laurel ^, t11uw *^ r711re1 Ilelwdr,• A AIC•Illllnl .. Phd„;Idn,•y .wl ,o Y ptrNF RV fawn L~l N .,l 1, ~~,vnlau, Cr, r' , O -'1' ,nrw ~`,, i Y7n, tvilln K,n man ,rwrau. • IAI :on 1 I Gnml!rlunn a O•` l\\CO tow --ti. (al K. r.mwnp New M• ~•i,~,,~,1.t". 1 c,d,u Cayuga O nP y nwere(x'n hulev •_• ~p WAVNE'iirwFan.--T• .... Crvslal~ rev 5 tint lP'll ~ v ~ : Waveland o li o° Irwnl„r,g 1 0 0.0? PARKE Ladog N rdnna,n OMeudunHas Kw; prelandhtew Castle ., F~',~r~- P I, .im-,,.^ x,da.•{ann~ 3Newporl osalem ° nmownsn ~ eh,,d RM,i ~ o r.a,nln„la.rdr ~. ~ ~' ( G,11im,s•n'e 1--- Lhrrsman,~ Oanaad 1ellVna NeNOa,cxs Greelttjelo- lrahtlc°"^O a IC,a1 rpFOLE Ilnlwuodp Iailhnm rl nl`«...pi-' I1 o. r;,~ on Roachdale i u:rdw~ ~ pe- III(h11100dI ncola t rv.n,.ln a s • M f y~errhl ~ s+, ~•.`. ~ _ lalorl•m. ~~Yton ._i•,11 I Cedalvdl'•r., l : ~ .(xRnekville Danville-m•" 1,m Newl'ale,lme oten` n' Mdmn ° M,7N1 6r I „ rlr')Uy;L AS SINrnnrier),« O ~ Mu3leyrdl• .v 1T Ii1nV - WMt,andna }l l`IIIO .. EDGAR 1 a Mecca PUTNAM CI.IYtno ~~~IU. 1''O +• Co1lhaRe rnvrriE UNIONa ;Ota6nv~ p n,wew l•7 m~ d1'GIIt t7 011--' Miamisfim alw r..n„rlnon ~`'• Inn.~~~ Arcul~c nlanlo, a Id P o Ruses ~ Camdrn Rqt r;ItE.r r, r• a1 ,1: o. ,CI. o P°rls -hntan ,1b, ' FI a,n1 MARION D~r]ox Monslown •~ Lib fly 0 OCermanlow 'r~lu~nr ,.'",. :~ D.111:uu1 ~ .(~, gasedale .61. Cann BFSVI)++e Pj ILaas ___,_ ' ~ i o Greencasf Fairland 1 r- ultan•a•. Fonlanelo earn+onr Mnnrovia,,ge• Greenwood) o Rushville wcunrgcl:an,er~-----frankln® r~wapnr vifle • ool Claverdnlr. {e,i o Shelb villa tlxlord O• WARNICrJ Ir l•tNrrul {harleslon n tear uar,leoBrozil,m, ° Itioo fllooklyn Y .©. Milroyo O FRANKLIN '7r ~ `~'I"° •I ,1, hm hlsnlla 1 (.al11Cl Middletown trhannll ~D. 1~ --~--' °~Ir,ut g M°r+c;rr+Pranklin•m• Waldrono .m. IOR Wr`,Iln4rl Y7•te1lP.na lerT~ T OwEN .Ql.• Jo.(NSON •m, NewMia, O Slehano„ '?, Wiln:uu)1„~ y y` Monnw N mitten , t~ ~ 1 1 .m. JTerf@ 1'tOUI@ Mariinsvllle SLPauI DECArvR Qrookvillc t"r I ^ 'a'1'•"I1e ----Mdtlllia.dl Mm Tnlnwn° Edinbwg SHELBY W Mason" K,., ~„•~,.,a.~ eeT nl~, ivn ,~1 Marshal IeLAr Gosport g• m. ~. °Oldenburg BuiLER ~'nrs M,u; ~'Rlanchr••'`~, 1~, mCase vtG° elaowN D,Ilnpeo Greensburg ~ DEAR IQA~~ ~ "" "' .;, Y CIaY Cilyo SpenceY•O• Morlr:oE laylerswlle Y ~-a,~Hanison lm'ratli prn.a,'rrl ,1,,,'~;f ); ^ II;II ••dn v CLARK o oElleltsville balesville eORN r+Awrn.ION I i~ Gn•raull larmersburg• Ny erg ,o. .®. Westport Creeo Addyston~5a Shelburne o Broadvie ~ • Nashville Columbus ° nawre~cehud~en ao Notwood~~ ~'~~~~1na~'1 45rEn SULLIVAN ~m ~ ~~ ~lul•.nnvdlrp - .~. p waTttoLO- Dsanod' Mdan .tD: ~«'"'~ Oalavian, . y:1n.a;~•~d~•~~r . 1a onville Wollllingtan 6loomington ,aEw _IENNINGS I .,j. Aur vra(11~ OVII1JYOn' r" t ... .. Linton l ew sort 5ullivon Versailles I p,1,I,,, 1„n r1 1Nw F en,,,n~., Robinson. Dagger ® .d. ~• ndlsbo,aq 9 A raarufr ,II LL.•6 ",.n.l ~.~ ,y tndnn~n .ro. nPalesline Bloomfield JACKSON N,V rnon n •{ ' Inds I„ . +•7' ~,., n•u,l~,.:• In l,~:•.r~ I..• ~, yonso o Vrrnrn, 'Ttn+tEV Rising.un.,j.. r'~ n. nrw Ilnr.lnn CIiAWFORO . O. GREENE Hrllonville freelown ® oHlo dcncr~^ AMr ,~,,„•i1 w~~,•'~'°~'•• a Callrsla Elnora litic~ • o Seymour -- ,A(,uNE rnfLL~ ~ ~. (lilt Hrnk ~--• o, Valtonia~•p. sv,rn Tr l.I wNn KEN ~,.1„drr, I;rnierl ~.,n _ OaYlawnO OsandlK••~ ~•ndnn R° ~"`a'n -^"'nstnwl JEFFERSON Wnik7n iON ~~ ~ ,,,., RICHL AND LAWRENCE I erbndvdle O~ O ~ O N. Madison \SOn~Narsa~+vs ~, + R'~' v1 lawrencevdle ~ Bicknellm row illn o ~~.,I! < rF.NDLF (Aur,~lsla~ . ,• ^pla.~N. Snnvn•r~ 0.~. arnr avdle° Monlgom b~ ~'` Nanevef clm~` O •C ~°'~rI GnANT t°N `Inu.,'..r ..~, ~~~ ~i~ u3linm Vevay \ r`'.~'1 Olne ll $collsburti ^ ~ r' n phrnh•rnr' Arid r Inll~f, Ww•aumd' ~ 1 ~ ~'o• ~o'•Cnrrolllnn p,r p,dg. •m• Ihm,k•.nIL• r YI P.I ). O F~. SCOTT .r, r~ :~,. labnnulh '1' J.1:,, - SLlranuswllr. YIO(CnnES We ~~ /~ty~l ' „ L,Wl-rawlfi;lmstnwn 4T j' '. , ,I DA` V~"~ \ \ iii/ CLARK •O• _ _ __. Yc.'?Inrnn nn,,,•lulr.(, • KNOx .. _- °Ilrnryville snedlnnl b, ' r,u ~),,•,•la'. wwaas Uwrnlnn ~ ~ ~-. __ C r1CStOWIl~~F1ENRy IIA17n ISON ~.r~~',~•' ~ 14: ' In ` .d,.Peli o f ~ aloka PIKE o 'o Ln hrangr. ~NrwCnS~lr. tti, „ i tlti•`j'° „r ~„ wr°•r-• nov eller'lTiurg / [ynlh;aaa.m. ~ ••r., ~ l..' , FA.1, Cgrmel Francis ~~ o i DuFac]IS Marenga° ~Mi111ownl (',larksvi 1'ca OLDA(n ia~• o[mn":Arc r ++I 3 ]~• ~• o Winslow SCOTT i. Mdlrwnwg~ i?. rtl,~` f eld O Nlmm Prineeion Huntingburg O. 4 Ol:res~w`gd~'~- r neNK ~. t w ~ • clnsoN Oaklond Cil ,o English ew A bany:, eAerson ills sHEl.or~ „" (eln•a+n \-, r•..uhsl,~ Y I howl lull (-i~ t o .q,.Fru i+, t •- i' n n, u ~.. `" OforlAlanch oNolland r.nwwronu ~ S11rlb vllle Ul,,lnmr,r, •I(, ensvillEn ~ u~ a • , v .il. I n I $,.- -s learr,lh - oH, J „ oI rdinond Ftnnk10t1 ~Mldnar , NF111E Cynlhiana ll W/ISlildl I,nnvdlc q r'Et7ny ~ Cn1 y1100 Q t5iit~~8 ITV.- U i~S tl(,t •:'.,. If•InSsvdlro ~.anutw~ Dale ^ ^ ~- ,( 11,,,,~!~r L@XinglOr\",r,pS ,, r•, Pose villa n„ ~,. wARRICK L•,. ,~•IJu HARRISON a ,Err En9oN ~ ! VPrsadlr - I ' d ,D n,. u.,.,~,_, n( ,il pll '',1.•.1 .®, Y I SP[Nr'IN r ~ L - taWn'ncrh s ~ „ 1 •11' n New Ilalmnn f-' MLWashin IooU crr.Nrrn urpr:y in. .{~ ,. .,..r~,~ Y Chan IPr a ~ n ql ~Nenn l'IS, m Carrnl o •1h•goonvllle \) tllrnv MEADE ~ Well Pt. rI„mot,,, ,j, ID 'NnINS lily rPUSEV I -~CVOnSV1II@ ~( Tell CII \ O. `• O O. IaTlmsville wNnrnsoN t~ ~ML,Anmr, ('. ..r ~ SS ~{ ~• III,,,,m ~ Rr dndenhul Sh,glhi`rdsvdlr ~°•• a Ilrr•nr r 1 nuK T 1 rai _ g v ~ ~Grandvlew ~ g ~ Rlnnndlcldo ""„"1 I Verri+311 N~',-wbU1 h ~` n b•l"ualnll~ln ~Mlddrnu hJorurl Knox ~~ fJirholasville~ ~r•o.,rt, ,. , ~ r-~ ~~ ' • ~ t1~. \ ~• • - 0 R 1 NFl SI IN. Wdnlnrr ~ ,~, ~'h. u , Irw h ,,., ••"'a~ d Aa k nrl'' ntC o.".'~ . hvinglgp ~ _ `~:.• MApISnN .. ~nLt.stlN ~ ~ ~ p .r11ti0 IIaWI!"Vln' n11ECKINR10nE (R11BIIr7111C1.' ,(p, vyAS111N0~ MtSfTCER Mlr.r I'6q' 1.111 F, ' ~.I-Nan (3FSOIt ~ tk ~ nVihe Gttl FL to R,dgw,Ir~ HENDCPSON ` -' ~r• !` .&haldinshlul; Bordslawn IoN Ib. OO. ) 1sTn.t ,rn,ra~,'.. ° /-.. tom. i'o..« /err. y nF,r,r,y,arrr, Harrodsburg°eurgar Riclt~mond f I Uniontown O Aw n,,.r,,, •~•nRlvrun, ~9 f ElirabellTlown S rill lirld • T'~• ;hr' w«sluwn (p, Croydon OWeD560(0 Whileol e .I~. ~ F. .~. PenyvilleIiuvi E I: vine ( l ~Mor anfield DAV1ESS Crciliao o ~ D'grivihe•rD• ~.=t.ancaslcl Brrco ~- Ncw Ilaven ~ Dc,,ilr•d~ g otmdsviUe HnnDIN MARION Park vd1 n olundinn Ily m ,IN • uN1oN Srhreeo oHl° { ,o•Nod envllle ~ 7 ~ildl ISwEeSrER ~L%1RUE~~ ~U •b• ~~' m RorA a i,.Dunn f. lhoun I~ernaue ~r ~ •~- jv °8ollulo ~~a~on ~IanInIA ~ c~sK L1'r "'~ " 1 •i, 'T nChy Mr•.:- ~ 1 oU,lon ~/'OrnJlord(.111r CrabUrchatd ~ " ' r'~ ~ LexN ul land i,•Ilullfnul lrilrhlirld r ~ nitrndbr.n l ,,,, „ , t rnInF.NDtr mProvidence nfleavcr ILm HAnY Invt_DR cns7:v \L,Nrr,,,. , HOrKINS n GRAYSON ~ sYayn.~ h° 1/~M1 Vrrnn I r~ l'inc 1611 ,j. fop Mcn~my C mp6ellsvlle a "-~..- ' ManrM ~Aa isonville •~1• s ' ' .,r ~ ~lallinglnnm ~`°t``~G~IIam~~nn11al(Cily AIJTLER Et,MONSO ~ ~ ` herly / l „ P Vii. ~'A Nnn, \~ ~ T /`.Mnrganlnwn Munlollfuillr Grel_n;hnlg r / rIN AT.KI \ ,rl ti,•u~. ~~'~, ,,. i, Drlkc'•h,nn ~ I! ,~Hmsr,C•we~17frrr AoAlr7 .~ `. tea' • MANHOUR FEE JUSTIFICATION I. LIST OF PROJECT PERSONNEL TASKS AND ESTIMATED MANHOURS A. PROJECT MANAGER/COORDINATING ENGINEER: The Project Manager and Coordinator will be Mr. Jorge I. Lanz, a licensed Professional Engineer, who will be responsible for managing the entire project construction, and oversee the Project Engineers and Resident Inspectors. Based on a construction period of 60 calendar days (45 working days), estimated hours are as follows: n LJ 1. Attend Pre-Construction Conference 2. Perform weekly inspections of construction with Project Engineer (4 hour/inspection week) 3. Check Final Construction Record 4. Attend Final Inspection with INDOT and FhWA TOTAL ESTIMATED MANHOURS B. PROJECT ENGINEER: 4 hours 4.5 hours 4 hours 2 hours 14.5 hours The Project Engineer will be Mr. Jim Silliman, an Engineer Trainee. His input in the construction of this project and estimated man-hours are as follows, based on a construction period of 45 working days: 1. Attend Pre-Construction Conference 2. Perform Daily Coordination with Resident Project Representative, either At Central Office or at Project Site (Assume present at site every other day, 0.5 hours/inspection week) 3. Prepare and check Final Construction Record 4. Attend Final Inspection with INDOT and FhWA 4 hours 4.5 hours 8 hours 4 hours • TOTAL ESTIMATED MANHOURS 20.5 hours ~~ C. RESIDENT PROJECT REPRESENTATIVE: The RPR will be Ms. Victoria L. Layton. Ms. Layton will be present at the site periodically during the entire construction period of the project. Ms. Layton is pre-qualified with the Seymour District of the Indiana Department of Transportation to perform this work. Estimated man-hours and task for Ms. Layton are as follows: 1. Attend Pre-Construction Conference 4 hours 2. Inspect construction, contractor supervision, be present at site 45 working days, 2 hrs. day avg. 90 hours 3. Prepare Final Construction Record and As-Built Plans 80 hours • 4. Attend Final Inspection 2 hours TOTAL ESTIMATED MAN-HOURS 176 hours D. PROJECT INSPECTOR: A project inspector will be required when the Contractor is performing multiple construction operations, hatching concrete, mixing asphalt, etc. Estimated man-hours for the Project Inspector include the following tasks: 1. Inspect Concrete Batching at Plant 4 hours 2. On site Job Inspection 16 hours TOTAL ESTIMATED MAN-HOURS 20 hours E. OTHER EXPENSES The only additional indirect expenses estimated by our firm to complete this project is trip mileage to the project site. This mileage will be as follows: 1. PROJECT MANAGER: 4 round trips x 6 mi./rd. trip = 24 mi. 2. PROJECT ENGINEER: 4 round trips x 6 mi./rd. trip = 24 mi. . 300 mi. 50 round tries x 6 mi.lyd. trip = 3 INSPECTORS : 348 ml TOTAL ESTIMATED MILEAGE _ $100.00 CONSTRUCTION RECORD = COPIES OF FINAL es from our offices. (The project site is located 3 6 es) . Therefore, one round trip = ESTIMATE OF PROPOSED FEE The estimated fee for this project is as follows: Ines . current overhead rate is 112.41 % • Allowance Per Jacobi, Toombs and Lanz, mile is $0.31. EXTENSION HOURS WAGE RATE CLASSIFICATION $ 659.75 14.5 45.50 PROJECT MANAGER $ 430.50 20.5 21.00 PROJECT ENGINEER $ 4,136.00 RESIDENT PROJECT 176 23.50 REPRESENTATIVE $ 390.00 • 20 19.50 INSPECTOR $ 384.00 24 16.00 CLERICAL- $ 6,000.25 TOTAL DIRECT LABOR: $ 6,744.88 INDIRECT COSTS: DIRECT LABOR x 1.1241 $ 12,745.13 TOTAL LABOR COSTS: $ 207.88 MILEAGE 348 Miles x $0.31 Per mile' COPIES ($100) $ TOTAL COST: $ 1,911.77 FIXED FEE: $ 14,864.78 CONSTRUCTION ENGINEERING COSTS: f 60 calendar This is aNOT-TO-EXCEED figure based on a construction period o • days. lyDIA1V,9 ~d O a Q a OF TR NT OF TRANSPORTATION INDIANA DEPART'ME Senate Avenue Room N725 Indianapolis, Indiana 46204-2 317 233-3691 (317) 232-536& FAX. ( ) An Equal Opportunity Employer • http://www•in•gov/dot JOSEPH E. KERNAN, Governor J. BRYANNICOL, Commissioner August 9, 2004 T0: Mr. Jorge I. Lanz, President Jacobi, Toombs and Lanz, Inc. Writer' s Direct Line gP; Report on Audit of Overhead Rate Jacobi, Toombs and Lanz, Inc. Overhead Rate for Calendar Year 2002 Audit Report No.: OS-12-2 records of Jacobi, Toombs and Lanz, Inc. for the purpose of We have audited the accounting ear 2002. Development of the establishing a fmal audit determined overhead rate for the calendar y d rate is the responsibility of the firm's management. Our responsibility is to express an opinion propose on these rates based on our audit. standards, 48 We conducted our audit in accordance with generally accepted government auditing 31.2 and the INDOT policies and rules applicable to cono able assuroance of hether~the ~ a se CFR Part p erform the audit to obtam real standards require that we lan and p in on a test basis, and records reviewed are free of material os~es u t~.he ~ an lre ords review wed• An audit al ell asludes evidence supporting the amounts and disc the Consultant, as w assessing the accounting principles used and significant estimates made by the overall presentation. We believe that our audit provides a reasonable basis for our opinion. evaluatmg e Consultant submitted a revised proposed overhead raead rate along with an ~Paanati°riof oure 'Ili overhead rate to b ems d~sallowedes presented in Exhibit~Aover adjustments and it ent average pay rates per labor classification were also audited and are p ro os d ~ Exlvbit B Curr of this report. These rates and labor classifications should be used when submitting p P ~` • CONSTRUCTION COST ESTIMATE The estimated Construction Cost of this project is $95,000.00. Preliminary Engineering Services were performed by another consultant. Please request itemized construction estimate from Steve Dilk at INDIANA DEPARTMENT OF TRANSPORTATION'S DIVISION OF LOCAL ASSISTANCE if this is required. • • state Form 3~zi3 (R/ii-se) STATEMENT OF AFFLRMATION ACTION. TO SOLICIT Form bBE4 • DISADVANTAGED BUSINESS ENTERPRISE SUBCONTRACTORS Contract Number. ~~ ` L(~ qss (~~: Project Number S~~ °1%'~ ~'C~ 2_q~ Type of work to be sublet 1~~~~ Proposed Subcontractor fV~ N`:~ This Subcontractor. (is) (is not) a Disadvantaged Business Enterprise. ~ ~ ~4 c.~ r 'r-F~ D,nnb ~ S rte, p r-~ 2 , ~ o- c. r i A ~--, ~yl.g ~ ~ v" '~`~ J""~~o ~`' u' ~ t ti'~y4~ - STATEMENT OF AFFIRMATIVE ACTION IMPORTANT! ` READ'.THE INSTRUCTIONS ON THE REVERSE SIDE OF THIS fORM DBE CONTACTS: t ..AGENCIES CONTACTED: WHY WAS A DBE CONTRACTOR NOT UTILIZED? ~- INDIANA'DEPARTMENT OF HIGHWAYS `-1 I ~i~/~-S1 ~ 'Z c^/t ' COMPANY E ~- ~ ~An REVIEWED BY DATE BY PA FFICER - TITLE J ~ ~N2 P` ~ L ~ ate: COM ANY DBE OFFICER DAT (Print or type)