SUBMIT COMPLETED APPLICATION TO:
DOUG MCCONNELL, CONTRACT ADMINISTRATOR
or
PUBLIC UTILITY DISTRICT NO.1 OF SKAGIT COUNTY
1415 FREEWAY DRIVE, POST OFFICE BOX 1436
MOUNT VERNON, WASHINGTON98273
SMALL WORKS ROSTER
APPLICATION FOR QUALIFICATION
Pursuant to RCW 54.04.070 and 39.04.155, Contractors wishing to be approved by the Public Utility District
No. 1 of Skagit County, Washington for inclusion on the Small Works Roster shall complete the following application and submit all required supporting information.
1.Name of Contractor:
2.Address of Contractor:
a. Mailing:
b. Business:
c. Phone Number ( )Email
3.Check as Appropriate: [ ] Incorporated [ ] Partnership [ ] Sole Proprietorship
If Incorporated, state resident agent and address. If Partnership or Sole Proprietorship, state managing person and address.
Name:
Mailing Address:
4.Federal Tax Identification Number:
5.Washington State Contractor's License Number:______
6.Complete Attachment A, identifying work categories for which you are seeking qualification.
7.Number of years applicant has performed the type of work for which applicant is bidding:.
8.Complete Attachment B, list clients for which work has been performed over the last three years including their names, addresses, phone numbers and location of jobs.
9.Complete Attachment C setting forth applicant's technical qualifications and organizational ability to perform the each type of work for which you are seeking qualification. This resume shall also include a list of your supervisory personnel and their qualifications and years of experience, a list of the number and type of craftsmen available and a list of equipment available for work.
10.The Contractor is required to pay prevailing wages in accordance with RCW 39.12 and RCW 54.04.090 and submit intent and affidavit forms to the District accordingly.
11.By signing this application, I certify that all work performed for the District under any Small Works Contract shall comply with WSDOT/APWA 2010, or current, Standard Specifications for Road, Bridge and Municipal Construction and APWA Supplement as amended by the specific Contract.
Application Signed ByTitleDate
DISTRICT APPROVAL: Date: ______
PUBLIC UTILITY DISTRICT No. 1 of SKAGIT COUNTY, WASHINGTON
SMALL WORKS ROSTER
QUALIFICATION CATEGORIES
[ATTACHMENT A]
Name of Applicant:
By use of an "X", indicate which of the following classes of work you are seeking qualification.
I. WATER FACILITY CONSTRUCTION
A. INSTALLATION
1. Concrete Cylinder Pipe______
2. Ductile Iron Pipe______
3. PVC Pipe______
4. HDPE Pipe______
5. Welded Steel Pipe______
6. Meters______
B. REPAIR
1. Concrete Cylinder Pipe______
2. Ductile Iron Pipe______
3. PVC Pipe______
4. HDPE Pipe______
5. Welded Steel Pipe______
6. Meters______
C. PUMPING STATION
1. Complete Installation______
2. Control Wiring and Metering______
3. Maintenance______
D. RESERVOIR STORAGE
1. Installation______
2. Maintenance:Cleaning______
Painting______
E. CLEARING AND GRUBBING ______
F. WATER TREATMENT FACILITY
1. Mechanical/Hydraulic Equipment______
2. Electrical Equipment______
3. Control Equipment______
4. Plant Subsystems______
PUBLIC UTILITY DISTRICT No. 1 of SKAGIT COUNTY, WASHINGTON
SMALL WORKS ROSTER
QUALIFICATION CATEGORIES
[ATTACHMENT A]
II. BUILDING AND MAINTENANCE CONSTRUCTION OR IMPROVEMENT WORK
A. GENERAL BUILDING
1. General Contractors______
2. Material Buildings Construction______
3. Remodel/Carpentry______
4. Roofing Repair______
5. Small Projects Maintenance/Repair______
Carpet, linoleum, wall covering installation______
Doors, windows, overhead doors______
6.Painting______
B. ELECTRICAL
1. Construction______
2. Maintenance______
C. HVAC (HEATING, VENTILATION, AIR CONDITIONING)
1. Construction______
2. Maintenance______
D. PLUMBING
1. Construction______
2. Maintenance______
E. HOUSEKEEPING
1. Janitorial/Custodial______
2. Specialty - Fire Damage Repair______
3. Specialty – Flood Damage______
F. GROUNDSKEEPING
1. Mowing and Trimming______
2. Spraying______
PUBLIC UTILITY DISTRICT No. 1 of SKAGIT COUNTY, WASHINGTON
SMALL WORKS ROSTER
QUALIFICATION CATEGORIES
[ATTACHMENT A]
III. CONSTRUCTION SPECIALTY WORK - CONSTRUCTION TYPE
A. ASBESTOS REMOVAL______
B. CONCRETE______
C. EXCAVATION/GRADING______
D. HAZARDOUS WASTE DISPOSAL______
E. MARINE WORK______
F. MASONRY______
G. METALS
1. Steel Fabrication______
2. Welding______
3. Machine Work______
H. ROOFING______
I. WELL DRILLER______
J. INDUSTRIAL PAINTING______
K. ASPHALT PAVING ______
IV. Miscellaneous (list any classifications not covered above)
PUBLIC UTILITY DISTRICT No.1 of SKAGIT COUNTY, WASHINGTON
PAGE ____ OF ____
SMALL WORKS ROSTER
3-YEAR HISTORY OF WORK
[ATTACHMENT B]
EXAMPLE:
Name/Location of Project: Line extension, Sedro-Woolley Nature and Scope of Work: Install 3,200 LF 8" DIP and 15 services along Cook Road
Total Price: $85,000 Completion Date: 8/15/09 Owner: J. C. Jacobs, Inc. Owner's Rep: Robert P. Jacobs Phone: (206) 856-9902
======
Name/Location of Project: Nature and Scope of Work:
Total Price: Completion Date: Owner: Owner's Rep: Phone: ______
______
Name/Location of Project: Nature and Scope of Work:
Total Price: Completion Date: Owner: Owner's Rep: Phone: ______
______
Name/Location of Project: Nature and Scope of Work:
Total Price: Completion Date: Owner: Owner's Rep: Phone: ______
______
Name/Location of Project: Nature and Scope of Work:
Total Price: Completion Date: Owner: Owner's Rep: Phone: ______
______
Name/Location of Project: Nature and Scope of Work:
Total Price: Completion Date: Owner: Owner's Rep: Phone: ______
______
Name/Location of Project: Nature and Scope of Work:
Total Price: Completion Date: Owner: Owner's Rep: Phone: ______
______
PUBLIC UTILITY DISTRICT No. 1 of SKAGIT COUNTY, WASHINGTON
SMALL WORKS ROSTER
GENERAL RESUME
[ATTACHMENT C]
Name of Applicant:
Work Category:
1. Technical Qualifications of the Firm (Number of years in business, license number, level of experience in this category, professional associations, etc.):
2. Organizational Ability of the Firm:
a. Supervisory Personnel (name, qualifications, years of experience):
1.
2.
3.
4.
b. Workforce of the Firm:
Trade (Carpenters, Operators, etc)Number usually employed
______
______
______
______
______
______
______
______
c. Equipment Assets of the Firm (Trucks, Backhoes, Loaders, etc):
ManufacturerModelConditionQuantity
NOTE:
Additional pages, or a Company brochure that provides all the above information, may be attached to this page.
PUBLIC UTILITY DISTRICT No.1 of SKAGIT COUNTY, WASHINGTON
SMALL WORKS ROSTER
AVAILABILITY OF COVERAGE
[TO BE COMPLETED BY AGENT OF SURETY (IES)]
1. BONDING: , hereinafter called "Surety", hereby certifies that , hereinafter called "Contractor", is covered by this Surety and has the capacity to be bonded for performance and payment of contract work with Public Utility District No. 1 of Skagit County, Washington in the amount not to exceed
dollars ($).
By:
Its:
Address of local office and agent of Surety:
======
2. INSURANCE: , hereinafter called "Insurer", hereby certifies that , hereinafter called "Contractor", is insured by this Insurance and can be covered to the following levels:
a. Public Liability Insurance in an amount not less than one million dollars ($1,000,000) combined single limit per occurrence for bodily injuries and death and/or property damage.
b. Property Damage Insurance in an amount not less than one million dollars ($1,000,000) per any one occurrence.
c. Builders Risk "All Risk" Insurance in an amount not less than the Total Contract Amount to include, but not limited to, loss by fire, earthquake, landslide, flood, damage resulting from faulty workmanship, materials design or construction furnished by the Contractor and vandalism.
By:
Its:
Address of local office and agent of Insurer: