26-27_RIsk_Approval_Request_for_Solicitation_(003)_-_Health_Dept_HVAC_Graphics-Controls.pdf

Bay County Purchasing Department Request for Solicitation

This form must be completed in its entirety prior to publication of any solicitation.

Solicitation Title: Date:

Requesting Department:

Department Point of Contact:

Office: Cell: Email:

Prepared by: Date:

Department Director Approval: Date:

Project Number, if applicable:

Funding Source? Please specify Funding Type (County, Surtax, FEMA, HUD, FDOT, LAP, ARPA, HMGP, CDBG, etc.):

If Grant funded, provide grant title/number:

If Grant not awarded/final, describe status and/or funding options:

Grantor approval/concurrence required before advertising or at contract approval?

Solicitation Yes ☐ No ☐ N/A ☐ Contract Yes ☐ No ☐ N/A ☐

Federal Requirements Yes ☐ No ☐ N/A ☐

Davis Bacon Yes ☐ No ☐ N/A ☐

Buy America Yes ☐ No ☐ N/A ☐

Buy American Yes ☐ No ☐ N/A ☐

Independent Cost Estimate Yes ☐ No ☐ N/A ☐

Pre-Bid Meeting Yes ☐ No ☐ N/A ☐ Mandatory Yes ☐ No ☐

Site Visit Yes ☐ No ☐ N/A ☐ Mandatory Yes ☐ No ☐

Permit Required Yes ☐ No ☐ N/A ☐ Entity:

Bonding Required Yes ☐ No ☐ N/A ☐ (Fl. Statute - Public Work >$200K required)

Design/Build Project Yes ☐ No ☐ N/A ☐ (Requires Design/Build Memo)

Contractor License (Type) Yes ☐ No ☐ N/A ☐ (General, Building, Electrical, Mechanical, Plumbing, etc.)

Professional License (Type) Yes ☐ No ☐ N/A ☐ (Architect, Engineer, etc)

Contract Term Requested:

Construction Contracts:

Liquidated Damages Amount $ Construction Time

Consultant assisting with Scope of Work/Specifications, Cost Estimate, or providing support documents Yes ☐ No ☐ N/A ☐ Consultant Name:

Introductory Paragraph (this should be a descriptive paragraph of the project)

This form must be completed in its entirety prior to publication of any solicitation.

Any Special Provisions?

De

No

Ch

Da Potential Vendors Budget Requirements partment Account Number Amount

Estimated Budget $ Approved FY Budget tes/Comments:

ief Financial Officer/Budget Office Approval te

This form must be completed in its entirety prior to publication of any solicitation.

Insurance Requirements Standard Insurance Requirements: $1M GL, $1M Business Auto, Work Comp, Additional Insurance Requirements:

Excess or Umbrella Liability Yes ☐ No ☐ N/A ☐

Professional Liability $ Yes ☐ No ☐ N/A ☐

Owners Protective Liability Yes ☐ No ☐ N/A ☐

Builders Risk Yes ☐ No ☐ N/A ☐

Installation Floater Yes ☐ No ☐ N/A ☐

Vendor’s Equipment Yes ☐ No ☐ N/A ☐

Pollution $ Yes ☐ No ☐ N/A ☐

USL&H Yes ☐ No ☐ N/A ☐

Jones Act Yes ☐ No ☐ N/A ☐ Other:

Other:

Other:

Chief Risk Officer /Risk Management Approval Date:

Solicitation Type

☐ Invitation to Bid (ITB) Based on lowest price

☐ Request for Proposal (RFP) Based on qualifications & price

☐ Request for Qualification (RFQ) Based on qualifications only.

CCNA/Federal Brooks Act may apply. CCNA compliance applies to Architects, Engineers, & Surveyors

Attachments: The following electronic documents provided to Purchasing

Scope of work/Specifications (word format) Yes ☐ No ☐ N/A ☐

A/E scope/specifications - Drawings/Plans Yes ☐ No ☐ N/A ☐

Grant Yes ☐ No ☐ N/A ☐

Design/Build Memo Yes ☐ No ☐ N/A ☐

Other Yes ☐ No ☐ N/A ☐ Purchasing Approvals

Date Received:

Date Approved for Advertising:

Assigned to:

Solicitation Number:

Purchasing Administrator:

Chief Procurement Officer: