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CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY" <br />DEVELOPMENT PROGRAM'! <br />FORM MWBE-1.0 <br />MBEIWBE PARTICIPATION <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects Involving MSl IMBE participation. <br />It is the bidder's sole responsibility to verify whether any listed minority or woman business meets the qualifications of a Minority or Women's <br />owned business. <br />Project Number: 118-043R Project Name: VP'A Restroorn RemodelinJt� ..., ....... <br />1 1 <br />Bidder: Larson Danielson Total Bid Amount: � t4 u j MBENVBE Goal: 7%/5 % <br />Construction Co., Inc„ <br />Page 1 of -3' <br />Name &Address of MBEJO <br />k <br />U <br />Primary Contact Person <br />(Name/Telephone) <br />ILA - �-S�f <br />q <br />Scope of Work to be Performed <br />(Attach scope/schedule if you need additional space) <br />11 '' <br />Z.C�1'�v'� c7-! lL <br />Doll&pmount of <br />�C� <br />MB ompanent <br />j <br />VI�\ <br />Percentage <br />of Total <br />BidlPro osal'. <br />Submitted by: <br />Timothy F. Laren, X 12/20/18 <br />' <br />Print Name president Signature Date <br />LARSON DANIELSON <br />spat <br />CONSTRUCTION CO,, INC. <br />