2-Attachment B- References.pdf

IFB 2000004148

Attachment B-1

REFERENCES

Provide three (3) references. Each reference should include name, address, telephone number and name of contact person.

PROJECT CONTACT/GENERAL CONTRACTOR OR OWNER:

1. Name: ___________________________________________________________

Address: _________________________________________________________

Telephone No.: ____________________________________________________

Contact Person: ___________________________________________________

2. Name: ___________________________________________________________

3. Name: ___________________________________________________________

Attachment B-2

PROJECT 1

DETAILS OF SIMILAR PROJECTS FOR WHICH BIDDER WAS PRIMARY CONTRACTOR

(90% OR MORE OF TOTAL PROJECT RESPONSIBILITY)

1. Bidder Name:________________________________________________________

Project Manager Name: _____________________________________________

Superintendent Name: ______________________________________________

2. Name of Project:________________________________

Contract Number: ________________________ Project Number___________

3. Owner Name: ___________________________________________________________

Address:_________________________________________________________

Contact Person: ___________________________________________________

Telephone Number: ( )_____________________________

4. Contract Dates – Attach additional information if project was not on schedule.

Started:____________

Original Contractual Completion: ____________

Final Contractual Completion: ______________

Actual Completion: _____________

5. Description of project: ____________________________________________________

6. Original Contract Value $___________________

Final Contract Value $_____________________

Value of Change Orders to Date: $________________

Value of Outstanding Claims to Date: $____________

PROJECT 1: CONTINUED

7. Name of Bonding Company: _______________________________________________

Contact Person: ___________________________________________________

8. Major Subcontractor(s)

Name: __________________________________________________________

Contact Person: ___________________________________________________

Role in Project: ____________________________________

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

Role in Project: ___________________________________

PROJECT 2

PROJECT 2: CONTINUED

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

PROJECT 3

Contact Person: ___________________________________________________

PROJECT 3: CONTINUED

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

Contact Person: ___________________________________________________

Role in Project: ___________________________________

Attachment B-3

SAFETY PROGRAM AND HISTORY

A. Does your firm have a written safety program?

Yes No _____

If yes, provide detail of your safety program on separate sheet.

B. Does the firm incorporate safety and health related issues into their new employee orientation programs?

C. Does the firm include work safety as a part of an employee's performance evaluation?

D. To what degree does senior/corporate management support safety related matters? Does the firm have a safety policy statement signed by a member of senior/corporate management?

Provide detail on separate sheet.

E. Does the firm have a full time Safety Manager? Does this person report to a high level, authoritative position within the Company?

If yes, provide detail on separate sheet.

F. Are safety inspections conducted at work sites? If so, how often and by whom?

G. Are safety training programs conducted for employees? If so, how often and by whom?

H. Are safety "tailgate meetings" and “toolbox meetings” conducted by the firm? If so, how frequently?

I. Does the firm have a visibly active safety committee? If so, how often does it meet? Who serves on the committee?

SAFETY PROGRAM AND HISTORY: CONTINUED

J. Is the firm an active member of a recognized construction safety organization in the Washington Metropolitan area, or in the state of contractor's domicile?

Yes No _____

K. What is the firm's Workers Compensation Experience Modification Factor? Are there any evident trends?

L. In the previous three years has your firm been cited for a serious violation, willful violation, violation for failure to abate or repeated violation (as defined by OSHA)?

If yes, provide details on next sheet.

M. Attach OSHA form 300 and OSHA form 300A with a summary of occupation injuries and illness for the last thirty-six (36) months.

SAFETY VIOLATIONS CERTIFICATE

List safety violations, Ref: Section 9 of the Special Provisions.

If there were no safety violations, execute the following certification:

I hereby certify that: has not received any citations (Name of Bidding Firm) for safety violations described in Special Provisions Section 9, which have become final within three years prior to bid submission.

Principal

State/Commonwealth of:

County of:

On this day of , 20 , after first being duly sworn, appeared before me, the undersigned Notary Public, and executed the foregoing instrument and acknowledged to me that he executed the same as and for the act and deed of said firm.

Notary Public

Seal

My commission expires on: , 20

Attachment B-4

CONTRACTOR DATA SHEET

Name and Address: ____________________________________________

Telephone No.: (____) _____________ Fax No.: (____) __________________

Email: ________________________________________________

Pay to Address (If different from above)

Virginia Contractor's License Number: _________________ Class: _______

Tax ID No. (Soc. Sec. No. If Sole Proprietor): _____________________________

Person who can respond authoritatively to any questions about this statement:

Name: _________________________ Title: _______________ _____________________

Email: __________________________ Tel.: ______________________________

Circle: Corporation Sole Proprietor Partnership

Joint Venture Other (Indicate) __________________

1. Organization

A. How many years has your organization been in business as a construction contractor?

B. How many years has your organization been in business under its present business name and license number?

CONTRACTOR DATA SHEET: CONTINUED

List license numbers, classifications and expiration dates of contractor licenses held by your firm.

C. Under what other or former names has your organization operated?

D. If your organization is a corporation, please indicate:

Date of incorporation: ____________

State of incorporation: ____________

President's name: _______________________

Vice President's name(s): _______________________

Secretary's name: _______________________

Treasurer's name: _______________________

E. If your organization is a partnership, please indicate:

Date of organization: _______________________

Type of partnership (if applicable): _______________________

Name(s) of general partners: _______________________

F. If your organization is a sole proprietorship, please indicate:

Date of organization: ___________________________________

Name of owner: _______________________________________

G. If the form of your organization is other than those listed above, describe it and name the principals and date of commencement of business:

H. Submit a copy of the bidder’s current organization chart showing numbers of employees by discipline and project and the names and titles down through Project Field Superintendent.

I. Provide proposed organizational chart for the project with names of key personnel.

J. Is the bidder related to another firm as a parent, subsidiary or affiliate?

Yes___ No___

If yes, give names and addresses of all affiliated parent and/or subsidiary companies.

Indicate which companies are subsidiaries.

K. Has there been any change in the ownership of the firm in the last three years?

L.

NOTE: A corporation whose shares are publicly traded is not required to answer this question.

Yes_______ No_________

If “yes,” explain on a separate signed page

2. Judgments

A. Has the bidder or any officer, director or owner thereof had any judgments entered against him within the past ten years for breach of contracts for governmental or non-governmental construction, including, but not limited to, design-build or construction management?

If yes, provide details on any such judgment.

3. Contract Compliance

A. Has your firm been found to be in substantial noncompliance with the terms and conditions of prior construction contracts in the past 10 years?

Yes No ______

If yes, provide details on any such instance.

B. Has the Bidder ever failed to complete any work awarded to it? If yes, state date(s), project(s), owner or A/E reference(s), and reason(s).

Yes _____ No ______

C. Has the bidder ever been party to a construction contract, which was terminated by the owner, for the owner’s convenience or otherwise? If yes, state date(s), project(s), owner or A/E reference(s), and reason(s).

D. Has the Bidder ever been declared to be in default or partial default on a construction contract or project? If yes, state date(s), project(s), owner or A/E reference(s), and reason(s).

E. Has the Owner or Owner’s Agent ever taken steps to complete contract work, which was the

Bidder own responsibility? If yes, indicate date(s), project(s), owner or A/E references, and reason(s).

F. Has the Bidder ever been the subject of a stop work order on a construction project? If yes, state date(s), project (s), and reason(s).

G. Are there any judgments, claims, suites, arbitration proceedings, or other legal proceedings pending or outstanding to which the Bidder is a party? If yes, state date(s), project(s), and reason(s).

H. Has the Bidder filed or caused to be filed, any suits, arbitration requests or claims with regard to any construction contracts within the past five (5) years? If yes, state date(s), project (s), and reason(s).

I. Has the Bidder been assessed liquidated damages for failure to complete a project by contract date within the past ten (10) years? If yes, state date(s), project (s), and reason(s).

J. Has the Bidder ever failed to complete punch list work on time.

4. Convictions

Has the bidder or any officer, director or owner thereof been convicted within the past ten (10) years of a crime related to governmental or non-governmental construction or contracting, including, but not limited to, violation of (i) Ethics in Public Contracting (Article 4 - § 11-72 et seq.), (ii) the Virginia Governmental Government (Chapter 4.2 - § 59.1 - 68.6 et seq.) of Title 59.1), or (iv) any substantially similar law of the United States or another state? If yes, provide details on any such convictions on a separate sheet.

5. Debarment

Is the bidder or any officer, director or owner thereof currently debarred pursuant to an established debarment procedure from bidding or contracting by any public body, agency of another state or agency of the federal government?

If yes, provide details: