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i \ <br /> 1 <br /> LR 109-3 <br /> ' Page4 of 4 <br /> Return With Bid <br /> OPTION FOR <br /> FUEL COST ADJUSTMENT <br /> 1 <br /> 1 The bidder shall submit this completed form with his/her bid. Failure to submit the form or <br /> properly complete contract number, company name, and sign and date the form shall make this <br /> contract exempt of fuel cost adjustments in all categories. Failure to indicate "Yes" for any <br /> category of work at the time of bid will make that category of work exempt from fuel cost <br /> iadjustment. After award, this form, when submitted shall become part of the contract. <br /> Contract No.: 19-00934-00-BR <br /> 1 <br /> Company Name: C-Hill Civil Contractors, Inc. <br /> i <br /> Contractor's s Option: <br /> Is your company opting to include this special provision as part of the contract plans for the <br /> following categories of work? <br /> Category A Earthwork. Yes ❑ <br /> Category B Subbases and Aggregate Base Courses Yes ❑ <br /> iCategory C HMA Bases, Pavements and Shoulders Yes ❑ <br /> Category D PCC Bases, Pavements and Shoulders Yes ❑ <br /> Category E Structures Yes ❑ <br /> ' Signature: Date: 01/12/24 <br /> 1 <br /> 1 <br /> 1 <br />