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ovTH - <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE DIVERSITY <br />DEVELOPMENT PROGRAM <br />FORM MWBE-1.0 <br />MBE/WBE PARTICIPATION abs. <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE/MBE 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: 116-127A Project Name: Sheridan Street and Sample Street Signal Improvements <br />Bidder: Walsh & Kelly. Inc. _ Total Bid Amount:_ $469,600.00 MBE/WBE Goal: 3.0% <br />Page 1 of. 1 <br />Primary Contact Person Scope of Work to be Performed Dollar Amount of Percentage <br />Name &Address of MBE/WBE (Name/Telephone) (Attach scope/schedule if you need additional space) MBENVBE Component of Total <br />RiWPmn 1 <br />State Barricading, Inc. James Michalski Maintaining of Traffic & Temporary <br />24963 US Highway 20 574-287-2078 Pavement Markings $14,144.98 3.0% <br />South Bend, IN 46628 <br />Submitted by:L — <br />P6N9pm16 John M. Peisker, President Signature <br />Version 4/2/2019 Contractor's Bid for Public Works - 10 <br />KE L% <br />y'✓ <br />QPORATF : Da% <br />�O <br />® $ 4 <br />; <br />,�i®ND t PSN <br />11111 <br />