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CITY OF SOUTH BEND MINORITY AND WOMEN BUSINESS ENTERPRISE INCLUSION PROGRAM PLAN FORM WBE-1.0 WBE UTILIZATION PLAN Version 03/15/2023 Page - 21 Public Works Quote This completed form should be supplied with Bids that pertain to City of South Bend Public Works Projects involving WBE participation. It is the bidder’s sole responsibility to verify whether any listed minority or woman business meets the WBE qualifications. Project Number: 123-042 Project Name: Century Center North Restroom Renovation Bidder: Total Bid Amount: WBE Goal: 1.5% Page_______of___ ____ Name & Address of WBE Primary Contact Person (Name/Telephone) Scope of Work to be Performed (Attach scope/schedule if you need additional space) Dollar Amount of WBE Component Percentage of Total Bid/Proposal Submitted by: Print Name Signature Date Larson-Danielson Const. Co., Inc.11Brian T. Larson, President X 5/23/23LARSON-DANIELSONCONSTRUCTION CO., INC.STATEOFINDIAANSEALCorporateNo Quotes from this Specific Scope