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SMI BE <br />O� <br />CITY OF SOUTH BEND <br />MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN :z <br />FORM WBE-1.0 <br />WBE UTILIZATION PLAN" <br />This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving WBE participation. It is <br />the bidder's sole responsibility to verify whether any listed woman -owned business meets the WBE qualifications. <br />Project Number: 120-049 Project Name: Randolph Park Area Improvements <br />Bidder: Premium Concrete Services Inc. Total Bid Amount: $156,485.00 WBE Goal: 2.4% <br />Page of <br />Submitted by: /?03 L3,CCAz.2 <br />Print Name Signiature <br />Version 08/25/2021 Contractor's Bid for Public Works - 9 <br />Date <br />331-7f,2_ <br />Primary Contact Person <br />Scope of Work to be Performed <br />Dollar Amount of WBE <br />Percentage <br />Total <br />Name &Address of WBE <br />(Name/Telephone) <br />(Attach scope/schedule if you need additional space) <br />Component <br />of <br />Bid/Proposal <br />State Barricading Inc. <br />James Michalski <br />Provide Maintenance of Trafic <br />$4290.00 <br />2.74 <br />24963 US 20 West <br />574-287-2078 <br />South Bend, IN 46628 <br />Submitted by: /?03 L3,CCAz.2 <br />Print Name Signiature <br />Version 08/25/2021 Contractor's Bid for Public Works - 9 <br />Date <br />331-7f,2_ <br />