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CITY OF SOUTH BEND MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM MBE-1.0 MBE UTILIZATION PLAN Version 03/15/2023 Page - 20 Public Works Quote This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving MBE participation. It is the bidder’s sole responsibility to verify whether any listed minority or woman business meets the MBE qualifications. Project Number: 123-042 Project Name: Century Center North Restroom Renovation Bidder: Total Bid Amount: MBE Goal: 0.5% Page_______of___ ____ Name & Address of MBE Primary Contact Person (Name/Telephone) Scope of Work to be Performed (Attach scope/schedule if you need additional space) Dollar Amount of MBE Component Percentage of Total Bid/Proposal Submitted by: Print Name Signature Date Larson-Danielson Const. Co., Inc.11Brian T. Larson, President X5/23/23LARSON-DANIELSONCONSTRUCTION CO., INC.STATEOFINDIAANSEALCorporateNo Quotes from this Specific Scope