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| KENTUCKY TRANSPORTATION CABINET |
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| DEPARTMENT OF HIGHWAYS |
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| DIVISION OF CONSTRUCTION PROCUREMENT |
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| DBE Plan/SUBCONTRACT REQUEST |
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| CONTRACT ID (CONTID) |
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| Subcontract # : |
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Page 1 of 3 |
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| TO : |
Rachel Mills, Director |
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Division of Construction Procurement |
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| FROM : |
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1st Tier Subcontractor: |
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Prime Contractor |
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(if applicable) |
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| SUBJECT : |
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County |
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Project Number |
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| I hereby request to utilize for DBE participation a portion of the subject project to: |
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Griffith, Ryan (KYTC):
DBE company name
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of |
Griffith, Ryan (KYTC):
Address of DBE company
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| DBE Employer Identification Numbers: |
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Federal |
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KY |
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| The amount to be subcontracted by this request is |
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DBE |
KYTC:
Dollar amount of DBE items based on DBE subcontracted unit prices.
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or |
0.00% |
Contract |
KYTC:
Dollar amount of DBE items based on the bid unit prices.
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0.00% |
of the |
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| (original contract ) or a subcontract amount of |
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KYTC:
Total Original Contract Amount
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Worth |
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KYTC:
Either Total Original Contract amount or Subcontract amount if Tier subcontract
$0.00 |
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| I have previously requested approval for subcontracts or agreements with other DBE as follows: |
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Contract "Worth" Amount |
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Contract % |
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| Name of DBE firm |
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DBE Amount |
DBE % |
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KYTC:
Based on DBE Unit Prices
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0.00% |
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KYTC:
based Contract "worth" Unit price. If full item of work, based on unit bid price, otherwise agreed to price if partial work item.
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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0.00% |
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| Totals based on original contract Amounts |
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$0.00 |
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0.00% |
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$0.00 |
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0.00% |
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KYTC:
Based on Contract Unit Prices
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| This section applicable if DBE firm is also a Subcontractor of work on Project: |
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| This subcontractor has been furnished a copy of Appendix B of 49 CFR Part 29 and advised to include |
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| the Certification in all lower tier covered transactions and in all solicitations for lower tier transactions |
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| (Federal Aid Contracts only). |
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| Prime Contractor's Signature |
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Date |
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| 1st Tier Subcontractor's Signature(if applicable) |
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Date |
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| DBE Participant Signature |
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Date |
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