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FIRST-TIER SUBCONTRACTOR DISCLOSURE STATEMENT <br />Project Title: Pavement Bond Measure - 29a' Avenue axid Willamette Street <br />Intersection hnprovements <br />City of Eugene Project No. 4513 <br />Bid Closing: Date: March 11, 2010 Time: 2:00 p.m. <br />Submit to: 99 E. Broadway, Suite 400, Eugene Oregon 97401 <br />Disclosure Deadline: 2:00 p.m. - This form must be submitted by bid closing date <br />and time. <br />Bidders are required to submit a first tier subcontractor disclosure form, substantially as described in <br />ORS 279C.370, prior to the Bid Closing Date and time. For this project the First-Tier <br />Subcontractor Disclosure Statement must be submitted regardless of the bid amount. <br />BIDDER INFORMATION <br />Bidder's Name: <br />Contact Person: V-a_ n q-AAV *V CAL, <br />Bidder's Telephone Number: 5 1- 33$- ~ 3y5 <br />F] Check here if the bid amount less deductive alternates, if any, is $100,000 or less. If the bid <br />amount less deductive alternates, if any, is equal to or less than $100,000, the remainder of the <br />form does not need to be completed, but the form must still be submitted. <br />List below the Name, Dollar Value, and Construction Contractors Board ("CCB") LicenseNumber, <br />and Category of Work that will be performed by each subcontractor that will be furnishing labor, or <br />labor and materials. Enter "NONE" if there are no subcontractors that need to be disclosed (IF <br />NEEDED, ATTACH ADDITIONAL SHEETS). <br />Name/Address <br />Dollar Value/CCB# <br />1) GA @ra►:;)kwr- <br />of Work <br />i vac, . 9L--t- 3) <br />