COMPANY QUALIFICATION STATEMENT

Transcription

1 SUBCONTRACTOR WORKSHEET COMPANY QUALIFICATION STATEMENT The submitting party certifies that the information provided herein is true and complete. Company Name: Company Webpage: Main Office Street Address: City, State, Zip Code: Post Office Address: City, State, Zip Code: Phone Number: Fax Number: Primary Contact Name: Title: Phone Number: Fax Number: Cell Phone Number: Address: Secondary Contact Name: Title: Phone Number: Fax Number: Cell Phone Number: Address:

2 1 ORGANIZATION 1.2 Type of Company (check all that apply) Subcontractor (Material and Installation) Vendor (Material Only) Architect Engineer Consultant Client 1.3 Construction Work Type (check all that apply) Multifamily and Residential Industrial and Manufacturing Medical Office Education Utilities and Treatment Retail Public Highways and Bridges Parking Structures Sports and Leisure 1.4 Enter the potential contract amount for the scope of work that your company is interested in pursuing (check all that apply) $0 to $250,000 $250,001 to $500,000 $1,000,000 to $5,000,000 $5,000,001 to $10,000,000 Above $10,000, How many years has your organization been in business? 1.6 How many years has your organization been in business under its present business name? Under what other or former names has your organization operated? 2 P age

3 1.7 Company Status Corporation Individual Partnership Joint Venture 1.8 If your organization is a corporation, answer the following: Date of incorporation: State of incorporation: President s name: Vice president s name(s): Secretary s name: Treasurer s name: 1.9 If your organization is a partnership, answer the following: Date of organization: Type of partnership (if applicable): Name(s) of general partner(s): 1.10 If your organization is individually owned, answer the following: Date of organization: Name of owner: 1.11 If your organization is a Joint Venture, describe it and name the principals. 2 LICENSING 2.2 Select trade categories in which your organization is legally qualified to do business. 2.3 Please select all that apply: Division General Contractors Owners Public Plan Room Reprographics ISQFT Insurance/Bond Requirements Government Agencies Utilities Temporary Labor Temporary Toilets Mobile Trailers 3 P age

4 01530 Temp Fences & Barricades Safety Equipment/Supplies Temporary Heat/Ventilation Construction Equipment Mobile Crane Tower Crane Material Hoist Cleaning Dumpsters and Trash Chutes 4 P age Division Site Contractor Blasting and Seismic Services Sand & Stone Suppliers Hazardous Material Abatement Site Remediation Demolition Sawcutting, Concrete/Asphalt Drilling Trucking Dewatering Shoring and Underpinning Soil Treatment Erosion and Sedimentation Control Tunneling, Boring, and Jacking Railroad Work Driven Piles Geopiers Drilled/Augercast Pilings Marine Work Site Domestic Water Wells Sanitary Sewage Gas Piping Subdrainage Storm Drainage Asphalt/Bituminous Pavement Concrete Pavement/Sidewalks Pavement Striping Curbs and Gutters Unit Pavers Stamped Concrete Athletic and Recreational Surfaces

5 02815 Fountains Fences and Gates Retaining Walls Guard Rails Road Appurtenances Prefabricated Bridges Site Furnishings Site and Street Shelters Play Field Equipment & Structures Traffic Signs and Signals Landscaping Irrigation Division Concrete Contractor Ready Mix Concrete Formwork Contractors Formwork Materials Concrete Reinforcement Reinforcement Installation Concrete Finishing Stamped Concrete CastStone Tilt up Concrete Cementitious Decks/Gypsum Concrete Industrial Concrete Flooring Contractors Lightweight concrete Roof Insulation Grouts Concrete Restoration and Cleaning Division Masonry Contractor Masonry Suppliers Stone Contractors Simulated Masonry Masonry Restoration and Cleaning 5 P age Division Structural Steel Suppliers Steel Erection Metal Joist Suppliers Epicore

6 05475 Lightgauge Metal Stud Trusses Metal Fabrications Manufactured Stairs/Railings Metal Castings Hydraulic Fabrications Unistrut Ornamental Metals/Railing Expansion Control Metal Restoration and Cleaning Division Wood Materials Wood Siding Materials Wood Framing Subcontractors Structural Panels Timber Construction Glued Lamination Construction Wood Trusses Architectural Woodwork Manufactured Cabinets Division Waterproofing and Sealants Traffic/Pedestrian Coating Building Insulation Sprayed Insulation Exterior Insulation and Finish Systems Shingles, Roof Tiles, and Roof Coverings Metal Roof and Wall Panels Composite Panels Vinyl Siding Membrane/Built Up Roof Flashing and Sheet Metal Roof Specialties and Accessories Applied Fireproofing Firestopping/Firecaulking 6 P age Division Doors/Frames/Hardware Doors and Hardware Installation Aluminum doors and Frames Pre Hung Wood Doors

7 08270 Sliding Mirror Closet doors Acoustic Doors Shower Doors Blast Resistant Doors Access Doors and Panels Coiling Doors/Grilles/Overhead Doors Folding Fire Doors Automatic Entrance Doors Revolving Entrance Doors Acoustic Windows Metal Windows Wood Windows Skylights Glass Contractors Division Plaster/Stucco GFRG Products Drywall Drywall Material Suppliers Tile & Stone Terrazzo Acoustical Ceilings Specialty Ceilings Carpet and Resilient Flooring Specialty Flooring Wood Flooring Fluid Applies/Epoxy Flooring Special Wall Finishes Acoustical Treatment Painting and Wallcovering In tumescent Thin Film Fireproofing 7 P age Division Specialties Installation Visual Display Boards Compartments and Cubicles Toilet Partitions Showers and Dressing Compartments Louvers and Vents Service Walls Wall and Corner Guards

8 10270 Access Flooring Fireplaces and Stoves Flagpoles Signage Pedestrian Control Devices Lockers Fire Protection Specialties Postal Specialties Wire Mesh Partitions Operable Partitions Storage/Wire Shelving Exterior Sun Control Devices Exterior Shutters Awnings and Canopies Telephone Specialties Toilet, Bath and Laundry Accessories 8 P age Division Theater Equipment Maintenance Equipment Window Washing Equipment Security and Vault Equipment Ecclesiastical Equipment Library Equipment Theater and Stage Equipment Mercantile Equipment Laundry Equipment Audio Visual Equipment Vehicle Service Equipment Fuel Dispensing Equipment Parking Control Equipment Loading Dock Equipment Solid Waste Handling Equipment Water Supply & Treatment Equipment Food Service Equipment Residential Appliances Darkroom Equipment Athletic/Recreation/Therapeutic Equip Industrial and Process Equipment Moveable Bridge Equipment Office Equipment Laboratory Equipment

9 11700 Medical Equipment Exhibit Equipment Division Laboratory Casework Furnishings and Accessories Rugs and Mats Window Treatments Multiple Seating System Furniture Division Special Purpose Room Cold Storage Room Saunas and Steam Rooms Sound, Vibration and Seismic Control Radiation Protection Radio Frequency Shielding Lightning Protection Pre Engineered Buildings Prefabricated Dome Structures Swimming Pools Aquatic Park Facilities Ice Rinks Storage Tanks Underground Storage Tanks Measurement and Control Instrumentation Solar and Wind Energy Equipment Low Temp Contractors Division Dumbwaiters Elevators/Escalators Lifts Material Handling Chutes Pneumatic Tube Systems Hoists and Cranes 9 P age Division Mechanical Insulation

10 15300 Fire Protection Contractors Halon System Contractors Plumbing Contractors Plumbing Material Suppliers HVAC Contractors HVAC Equipment Suppliers Refrigeration Contractors HVAC Instrumentation and Controls Testing, Adjusting and Balancing Division Electrical Contractor Emergency Generators Instrumentation Lighting Suppliers Miscellaneous Communications Contractor Bridge and Road Work Geotechnical Services Civil Engineer Mechanical Engineer Architect Landscape Design Parking Consultants Elevator Consultants Waterproofing Consultants Interior Designers Food Service Consultants Medical Equipment Consultants Construction Management Reprographic Center Construct Document Review Consultant Testing and Special Inspections Commissioning Agents Scheduling Photography Surveying 10 P age

11 2.4 Please select state(s) in which your company pursues work, and provide corresponding license Number(s): State License Number State License Number Alaska AK Montana MT Alabama AL North Carolina NC Arkansas AR North Dakota ND Arizona AZ Nebraska NE California CA New Hampshire Colorado CO New Jersey NJ Connecticut CT New Mexico NM District of Columbia Nevada NV Delaware DE New York NY Florida FL Ohio OH Georgia GA Oklahoma OK Hawaii HI Oregon OR Iowa IA Pennsylvania PA Illinois IL Rhode Island RI Indiana IN South Carolina SC Kansas KS South Dakota SD Kentucky KY Tennessee TN Louisiana LA Texas TX Massachusetts MA Utah UT Maryland MD Virginia VA Maine ME Vermont VT Michigan MI Washington WA Minnesota MN Wisconsin WI Missouri MO West Virginia WV Mississippi MS Wyoming WY 2.5 List any additional jurisdictions and license numbers in which your organization is legally qualified to do business. 11 P age

12 2.6 Please check each of the following that applies to your organization: 3 EXPERIENCE Minority Business Type: Minority Women Disadvantaged Veteran Small Business Other (specify) Certification Number: 3.2 List your company s annual volume for the past five (5) years: 2011: 2010: 2009: 2008: 2007: 3.3 List your company s largest contract to date: Job Name: Value: Date Completed: 3.4 State total worth of work in progress and under contract to date: Total work under contract and in progress: Total work under contract and not yet started: 3.5 List at least three major construction projects your organization currently has in progress: Architect: Contract Amount: Scheduled Completion Date: Architect: Contract Amount: Scheduled Completion Date: 12 P a g e

13 Architect: Contract Amount: Scheduled Completion Date: Architect: Contract Amount: Scheduled Completion Date: Architect: Contract Amount: Scheduled Completion Date: *Attach any additional projects. 3.6 List at least three (3) major projects your company has completed in the past five (5) years: Architect: Contract Amount: Completion Date: Architect: Contract Amount: Scheduled Completion Date: 13 P age

14 Architect: Contract Amount: Scheduled Completion Date: Architect: Contract Amount: Scheduled Completion Date: Architect: Contract Amount: Scheduled Completion Date: *Attach any additional projects. 3.7 List the projects your organization currently has in progress and/or the most recent projects your organization has completed with Robertson Construction: Contract Amount: Robertson Project Manager (if applicable): Completion Date: Robertson Superintendent (if applicable): Contract Amount: Robertson Project Manager (if applicable): Completion Date: Robertson Superintendent (if applicable): 14 P a g e

15 Contract Amount: Comple Date: Robertson Project Manager (if applicable): Robertson Superintendent (if applicable): Project on: Contract Amount: Comple Date: Robertson Project Manager (if applicable): Robertson Superintendent (if applicable): Project on: Contract Amount: Comple Date: Robertson Project Manager (if applicable): Robertson Superintendent (if applicable): *A ach any a projects. 3.8 List total number of field employees that your company currently employs. 3.9 List total number of office employees that your company currently employs What percentage of work does your company perform with its own force? 3.11 List the categories of work that your orga normally self performs: 3.12 Provide worker compensa on experience modifi on rate for the past five (5) years: 15 P a g e 2011: 2010: 2009: 2008: 2007: 3.13 Does your company have an OSHA compliant safety program? Yes No 3.14 Has your company received any OSHA within the last three (3) years? Yes No

16 If you answered Yes, please provide the following information: OSHA Inspection Activity Number: Date of Inspection: Brief Description of Citation: Monetary Penalty: 3.15 Provide a breakdown of the total number of recordable injury and illness cases that occurred during the year: Total number of deaths: Total number of cases with days away from work: Total number of cases with job transfer or restriction: Total number of other recordable cases: 3.16 Provide the total number of hours all employees actually worked last year: 3.17 Attach a copy of the OSHA 300A Summary of Work Related Injuries and Illnesses Does your company have a Drug Abuse Policy with includes pre hire, random, and postaccident drug testing? Yes No 3.19 Does your company employ a Safety Director? Yes No If you answered Yes, how frequently will he/she perform inspections on the construction site? 3.20 Claims and Suits. (If the answer to any of the following questions is yes, please attach details.) Has your organization ever failed to complete any work awarded to it? Yes No Are there any judgments, claims, arbitration proceedings or suit pending or outstanding against your organization or its officers? Yes No Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last five (5) years? Yes No 3.21 Within the last five (5) years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? (If the answer is yes, please attach details.) Yes No 16 P age

17 4 REFERENCES 4.2 Trade Reverences: Firm Name: Contact: Address: City, State, Zip: Phone: Firm Name: Contact: Address: City, State, Zip: Phone: Firm Name: Contact: Address: City, State, Zip: Phone: Firm Name: Contact: Address: City, State, Zip: Phone: 4.3 Financial Institution References: Financial Institution: Contact: Address: City, State, Zip: Phone: Financial Institution: Contact: Address: City, State, Zip: Phone: 4.4 Is your company capable of providing a payment and performance bond equal to 100% of the contract amount? If "no," 4.4, 4.5, 4.6 and 4.7 do not apply. Yes No 4.5 Bond Premium (Provide % to add to contract amount based on $1,000,000 contract). 17 P age

18 4.6 State the name and rating of your bonding company. Surety Company: Contact: Address: City, State, Zip: Phone: Rating: 4.7 State the name of your bonding agent and your bonding capacity. Company: Contact: Address: City, State, Zip: Phone: Aggregate Bonding Capacity: Single Project Bonding Capacity: Current Bond Capacity 4.8 Provide a certified letter from your surety company acknowledging that your firm would be provided performance and payment bonds on future projects and the total aggregate and single project bonding capacity available for your firm. 5 FINANCIAL INFORMATION 5.2 Dun & Bradstreet Business Rating: 5.3 Please attach your most current complete audited financial statement. 6 Enter additional information here: 18 P age