Lake County Schools
CONSTRUCTION SERVICES PREQUALIFICATION
Application
DATE
Project Name: East Ridge High School Roof Replacement
Estimated Construction Cost: $600,000.00
Project Scope: Replacement of roofs on buildings #7, #8, and #9 at East Ridge High School all in accordance with specifications of Bid #3509BM
Project Number(s): Bid #3509BM
Submitted by:
Address:
Telephone / Fax Number:
Check One: A Corporation () A Partnership () An Individual () A Joint Venture ()
Check one: Prequalification Request: Annual This project Only
Please accept our application for certification as a pre-qualified contractor for the project listed above for Lake County Schools, or annually. It is understood that certification, if given, will be valid for the project that I have indicated above based on the information provided to me by Lake County Schools. If I indicate an annual prequalification and it is approved a certificate will be issued indicating an approved prequalification status one year from Board approval. I understand that if requesting to be bonded that the bonding capacity of my company should equal or exceed the aggregate amount of the project(s).
We authorize and request any public official, engineer, architect, surety company, bank depository, credit union, credit bureau or material or equipment manufacturer or distributor or any other person, firm or corporation to furnish any information requested by the Lake County School Board, to verify statements given in this application and to comment on our standing and general reputation within the community.
The costs incurred by the respondent in submitting its proposal are considered an operational cost of the respondent and shall not be passed on or borne by the School Board under any circumstances. All materials received shall be considered property of the Lake County School Board.
A copy of the license under which our firm is engaged in the business of contracting in the State of Florida is attached. This license was issued in accordance with the provisions of Section 489-113, Florida Statutes and is currently valid and in force. We agree to comply with all local, State and Federal Requirements, Laws, Rules and Regulations as they may apply to each project, including the State of Florida Jessica Lunsford Act requiring Level II Background Screening .
If a Corporation: If a Partnership or Individual Proprietorship:
Date of Incorporation Date of Organization
State of Incorporation If a partnership, state whether it is a general or
limited partnership
Affix Seal
By:______Date
Signature
Print name and title of authorized corporate officer signing above
Witness:______
Signature
Printed name:
Prequalification
GENERAL INFORMATION
Questionnaire
(Corporation) (Partnership or Individual Proprietorship)
Name of Officers: Name and Address of Owners and/or Partners:
President
Vice President
Secretary
Treasurer
Current Firm Name:
How many years has this firm been in business?
Previous Firm Name:
How many years had the pervious firm been in business?
Indicate Firm History (chronology)
SUBSIDIARY or AFFILIATED COMPANIES IN WHICH PRINCIPALS HAVE FINANCIAL INTERESTName and Address of Subsidiary or
Affiliated Companies / Explain in detail the Principal’s interest in this
Company and Nature of Business
List the type license and trade categories in which your organization is legally qualified to do business, indicate license numbers if applicable and include copies of current licenses with your application:
1. Is your Firm currently pre-qualified with any government agency? yes no.
If yes, please list agency/agencies.
2. Within the previous five (5) fiscal years, has your Firm been denied a contract award on which you submitted the low bid in competitive bidding, or been refused prequalification? yes no.
If yes, please explain.
3. Within the previous five (5) fiscal years, has your Firm failed to complete a project?
yes no.
If yes, state the name of the project, the Firm responsible, and the reason for failure to complete.
4. Within the previous five (5) fiscal years, has your Firm been involved in litigation?
yes no.
If yes, state the name of the project, the Firm responsible, and explain the nature and current status.
5. Within the previous five (5) fiscal years has there been any liquidated damages, penalties, liens, defaults, or cancellations imposed or filed against your Firm? yes no.
If yes, state the name of the project, the Firm responsible, and explain the nature and current status.
6. Within the previous five (5) fiscal years, has your Firm declared bankruptcy? yes no.
If yes, please explain.
a. Has a claim ever been filed with any surety based directly or indirectly on a construction project in which you were or are involved? yes no
If yes, explain
b. Has the Prime Firm or any of its subsidiary’s ever filed a claim against a Public entity with which it had contracted as a result of a contract dispute? Yes No If so explain below
7. Provide letters of reference and recommendations from previous owners and architects and attach to this questionnaire.
8. Safety: Please include the following information for the last three years:
Year 1 / Year 2 / CurrentWorkers’ Comp Experience Mod Rate
# of claims other than employee claims related to construction site work
Number, if any, of any OSHA related fines (Explain on a separate page)
Total number of jobsite fatalities, if any (Explain on a separate sheet)
Name of Comp Insurer
RELATED BUILDING EXPERIENCE
COMPLETED PROJECTS
Major consideration will be given to the successful completion of previous projects comparable in scope and complexity.
1. List the most recently completed projects, (within past five years), which best illustrate the experience of the Firm and the current staffing. List no less than three (3).
(Duplicate this two page form as necessary to list projects)
a.
Project Name:Project Location:
Project Scope:
Project Size:
(gross square feet)
Original Contract Amount: / $ / Final Contract Amount: / $
Explain Differences in “Contract Amounts”
b.
Firm’s Responsibility:
(Construction Manager, Project Manager, General Contractor, Design/Build, etc.)
Project Staff:
Principal in Charge:
Project Manager:
Superintendent:
Other:
c.
Completion Dates:
Original: / Revised: / Actual:
Explain Differences in “Completion Dates”
d.
Owner:
Contact Person & Title
Address:
Telephone & Fax:
e.
Project Architect/Engineer:
Address:
Telephone & Fax:
Contact Person & Title
RELATED BUILDING EXPERIENCE
IN PROGRESS PROJECTS
Major consideration will be given to the successful completion of previous projects comparable scope and complexity.
2. List and indicate the status of in progress projects under contract as of the date of this Application. Indicate whether the project is in progress or awarded and not yet begun.
(Duplicate this two page form as necessary to list projects)
a.
Project Name:Project Location:
Project Scope:
Project Size:
(gross square feet)
Total Amount of Your Contract: / $
Amount of Above Sublet to Others: / $
Uncompleted Amount of Contract / $
b.
Firm’s Responsibility:
(Construction Manager, Project Manager, General Contractor, Design/Build, etc.)
Project Staff:
Principal in Charge:
Project Manager:
Superintendent:
Other:
c.
Contract Status:
(Awarded & Not Yet Begun, In Progress, In Progress & Stopped, etc.)
Explanation:
Is the Project on schedule? yes no.
If no, please explain:d.
Owner:
Contact Person & Title
Address:
Telephone & Fax:
e.
Project Architect/Engineer:
Address:
Telephone & Fax:
Contact Person & Title
FINANCIAL CAPABILITY STATEMENT
Firm Name:
Complete the following:
Total Billingsfor Previous Three (3) Fiscal Years / Estimated total value of uncompleted work on outstanding contracts
Year / Year
$ / $
$ / $
$ / $
Bonding: Attach written verification of bonding capacity. The verification must be submitted by a licensed surety company having an A.M. Best’s rating of A- or greater, in the current A.M. Best Guide and must be qualified to do business in the State of Florida. The bonding capacity should indicate the available bonding capacity of your company for a single project and for multiple projects. The rating should also be included.
Name of Bonding Company:
Name, phone number and address of Florida registered agent for bonding company:
Name Phone
Address
OR
In the absence of such written bonding verification attach an audited financial statement current within the past 12 months including your organization’s latest balance sheet and income statement showing the following items:
Ø Current assets (cash, joint venture accounts, accounts receivable, notes receivable, accrued income, deposits, materials inventory and prepaid expenses)
Ø Net fixed assets
Ø Other assets
Ø Current liabilities (accounts payable, notes payable, accrued expenses, provisions for income taxes, advances, accrued salaries and accrued payroll taxes).
Ø Other liabilities (capital, capital stock, authorized and outstanding shares par values, earned surplus and retained earnings)
Name and address of firm preparing financial statement and date thereof:
Indicate the identical name of the organization for which the Financial Statement applies
Indicate the relationship of the company named in the Financial Report to the Company applying for Pre-Qualification (Parent,subsidiary)
Is the Parent or subsidiary prepared to act as the Guarantor of the Contract for Construction and Authorized to do so under the laws of Florida?
If so provide documentation
Please provide bank and credit references:
Bank Name
Contact: Phone
Address
INSURANCE REQUIREMENTS
INSURANCE: The CONTRACTOR shall not commence any construction work in connection with this Agreement until he has obtained all of the following types of insurance and such insurance has been approved by the Owner, nor shall the CONTRACTOR allow any subcontractor to commence work on his subcontract until all similar insurance required of the subcontractor has been so obtained and approved. All insurance policies shall be with insurers qualified and doing business in Florida:
WORKER'S COMPENSATION INSURANCE: The CONTRACTOR shall take out and maintain during the life of this Agreement Worker's Compensation Insurance for all his employees connected with the work of this Project and, in case any work is sublet, the CONTRACTOR shall require the subcontractor similarly to provide Worker's Compensation Insurance for all of the latter's employee unless such employees are covered by the protection afforded by the CONTRACTOR. Such insurance shall comply with the Florida Worker's Compensation Law with minimum Statutory/$1,000,000 limits. In case any class of employees engaged in hazardous work under this contract at the site of the project is not protected under the Worker's Compensation statute, the CONTRACTOR shall provide adequate insurance, satisfactory to the Owner, for the protection of employees not otherwise protected.
CONTRACTOR'S GENERAL LIABILITY AND PROPERTY DAMAGE INSURANCE: The CONTRACTOR shall take out and maintain during the life of this Agreement Comprehensive General Liability and Comprehensive Automobile Liability Insurance as shall protect him from claims for damage for personal injury, including accidental death, as well as claims for property damages which may arise from operating under this Agreement whether such operations are by himself or by anyone directly or indirectly employed by him and shall ensure that all of such policies list the Owner as an additional insured. The Amount of such insurance shall be minimum limits as follows:
A. Contractor's Comprehensive $2,000,000 General Liability Coverage, including Operations and Completed Operations, Pollution Liability, Bodily Injury and Property Damage. Each Occurrence, Combined Single Limit.
B. Automobile Liability Coverage, $500,000 Bodily Injury and Property Damage. Each Occurrence, Combined Single Limit.
C. Excess Liability, Umbrella Form $3,000,000. Each Occurrence, Combined Single Limit.
D. Other (or increased amounts of) insurance that the Owner may from time to time deem advisable or appropriate, at the Owner’s expense. Such new or additional insurance shall be effective as of the sooner of ninety (90) days after notice thereof or the next annual renewal of any policy being increased (as applicable).
The Insurance clause for both BODILY INJURY AND PROPERTY DAMAGE shall be amended to provide coverage on an occurrence basis.
The CONTRACTOR shall ensure that a Waiver of Subrogation be provided in favor of the District and, except as to Worker’s Compensation, the Owner is named as an additional insured under all policies of insurance required pursuant to this Agreement. Such policies shall contain a “severability of interest” or “cross liability” clause without obligation for premium payment of the Owner. The CONTRACTOR shall provide to the Owner a copy of any and all policies required by this Agreement upon request. A letter from the insuring agent shall be provided indicating the dollar cost for this Project only.
The CONTRACTOR shall ensure that all insurance policies required are issued by companies that are (1) authorized by subsisting certificates of authority by the Department of Insurance of the State of Florida or (2) an eligible surplus lines insurer under Florida Statutes. In addition, the insurer must have a Best’s Rating of “A” or better according to the latest edition of Best’s Key Rating Guide, published by A.M. Best Company.
SUBCONTRACTOR'S GENERAL LIABILITY AND PROPERTY DAMAGE INSURANCE: The CONTRACTOR shall require each of his subcontractors to procure and maintain during the life of this subcontract, insurance of the type specified above or insure the activities of his subcontractors in his policy, as specified above.
BUILDER'S RISK COVERAGE: The CONTRACTOR shall take out and maintain during the life of this Agreement a “Builder’s Risk Policy” completed value form, issued to provide coverage on an “all risk” basis including theft, in an amount not less than the cost of the improvements to the building. Policy premiums and deductibles will be the responsibility of the CONTRACTOR. The CONTRACTOR shall ensure that this coverage shall not lapse or be canceled because of partial occupancy by the Owner prior to acceptance of the Project.
CERTIFICATE OF INSURANCE: The Owner shall be furnished proof of Coverage of Insurance as follows:
A. Certificate of Insurance form will be furnished to the Owner along with the Contract Documents. These shall be completed and signed by the authorized Resident agent. This Certificate shall be dated, signed and shall include the following:
1. The name of the insured Contractor, the specific job by name and job number, the name of the insurer, the number of the policy, its effective date, and its termination date.
2. The CONTRACTOR shall be responsible for assuring that all required insurance remains in force for the duration of this Agreement, and shall notify Owner within 48 hours upon receipt of any cancellation or intent to non-renew notice or change in coverage limits or carriers. If the insurance is scheduled to expire during the contractual period, the CONTRACTOR shall be responsible for submitting new or renewed certificates of insurance to the Owner at a minimum of fifteen (15) calendar days in advance of such expiration.