|
|
|
|
|
|
|
|
|
|
|
|
|
KENTUCKY TRANSPORTATION CABINET |
|
|
DEPARTMENT OF HIGHWAYS |
|
|
DIVISION OF CONSTRUCTION PROCUREMENT |
|
|
DBE Plan/SUBCONTRACT REQUEST |
|
|
CONTRACT ID (CONTID) |
|
|
|
|
|
|
|
|
|
|
|
|
Subcontract # : |
|
|
|
|
|
|
|
|
Page 1 of 3 |
|
|
TO : |
Rachel Mills, Director |
|
|
|
|
|
|
|
|
|
|
|
|
Division of Construction Procurement |
|
|
|
|
|
|
|
|
|
|
|
FROM : |
|
1st Tier Subcontractor: |
|
|
|
|
|
Prime Contractor |
|
|
|
(if applicable) |
|
|
|
|
|
|
|
SUBJECT : |
|
|
|
|
|
|
|
County |
|
Project Number |
|
|
|
I hereby request to utilize for DBE participation a portion of the subject project to: |
|
|
|
|
|
|
|
|
|
|
|
|
Griffith, Ryan (KYTC):
DBE company name
|
of |
Griffith, Ryan (KYTC):
Address of DBE company
|
|
|
|
DBE Employer Identification Numbers: |
|
Federal |
|
KY |
|
|
|
|
|
|
|
|
The amount to be subcontracted by this request is |
|
DBE |
KYTC:
Dollar amount of DBE items based on DBE subcontracted unit prices.
|
or |
0.00% |
Contract |
KYTC:
Dollar amount of DBE items based on the bid unit prices.
|
or |
0.00% |
of the |
|
|
(original contract ) or a subcontract amount of |
|
|
|
KYTC:
Total Original Contract Amount
|
Worth |
|
KYTC:
Either Total Original Contract amount or Subcontract amount if Tier subcontract
$0.00 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
I have previously requested approval for subcontracts or agreements with other DBE as follows: |
|
|
|
|
|
|
Contract "Worth" Amount |
|
Contract % |
|
|
|
Name of DBE firm |
|
DBE Amount |
DBE % |
|
|
|
|
|
|
|
KYTC:
Based on DBE Unit Prices
|
|
0.00% |
|
KYTC:
based Contract "worth" Unit price. If full item of work, based on unit bid price, otherwise agreed to price if partial work item.
|
|
0.00% |
|
|
|
|
|
|
|
0.00% |
|
|
|
0.00% |
|
|
|
|
|
|
|
0.00% |
|
|
|
0.00% |
|
|
|
|
|
|
|
0.00% |
|
|
|
0.00% |
|
|
|
|
|
|
|
0.00% |
|
|
|
0.00% |
|
|
|
|
|
|
|
0.00% |
|
|
|
0.00% |
|
|
|
|
|
|
|
0.00% |
|
|
|
0.00% |
|
|
|
Totals based on original contract Amounts |
|
|
$0.00 |
|
0.00% |
|
$0.00 |
|
0.00% |
|
|
|
|
|
|
KYTC:
Based on Contract Unit Prices
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
This section applicable if DBE firm is also a Subcontractor of work on Project: |
|
|
|
|
|
|
|
|
|
|
|
|
This subcontractor has been furnished a copy of Appendix B of 49 CFR Part 29 and advised to include |
|
|
|
|
|
|
|
|
|
|
|
|
the Certification in all lower tier covered transactions and in all solicitations for lower tier transactions |
|
|
|
|
|
|
|
|
|
|
|
|
(Federal Aid Contracts only). |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Prime Contractor's Signature |
|
|
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1st Tier Subcontractor's Signature(if applicable) |
|
|
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DBE Participant Signature |
|
|
|
|
Date |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|