Attachment A-5 Special Historic Qualifications Forms for General Contractor and Roofing.docx

Note: Submit with Bid

FORM A-5

SPECIAL QUALIFICATIONS: COVER SHEET AND HISTORIC PRESERVATION CONTRACTOR QUALIFYING WORK EXPERIENCE REFERENCE FORM

Procurement #11568R Historic Hughes House Exterior Repairs and Preservation Project at Cape Blanco State Park (Roofing Phase)

(General Contractor)

Name of Firm

Mailing Address

Bidder’s Point Of Contact

Telephone Fax

(Name of Firm) accepts all the terms and conditions contained in the Historic Preservation Contractor Qualification Submittal.

CERTIFICATION:

I, ___________________________, certify that I am (title)__________________________ of the company herein listed and that the statements made in this document are true and accurate. I understand that if I fail to provide all the required information in the submittal, or if after attempting to contact the persons whose names I provide, the evaluation panel is still unable, having made reasonable effort, to verify the information furnished in my submittal, my bid may be rejected as nonresponsive at the sole discretion of OPRD.

Signature of authorized representative Date

Typed name of authorized representative Firm’s Federal Tax ID Number

Procurement # 11568R Historic Hughes House Exterior Repairs and Preservation Project at Cape Blanco State Park (Roofing Phase) Historic Preservation Contractor Qualifying Work Experience Reference Form General Contractor (page 1 of 3)

Name of proposed Historic Preservation General Contractor (Bidder):

Bidder must provide verifiable references for projects on which the contractor has successfully completed, (the general contractor) within the last ten (10) years, historic preservation work on a minimum of three (3) historic buildings listed on the National Register of Historic Places. Total contract must meet or exceed stated minimums to qualify.

Historic Building Name:

Street Address:

City/State:

Total Contract Price at Completion including Change Orders:

(Must meet minimum $100,000.00 value to qualify.)

Project satisfies contractor’s required Special Historic Qualifications? (Yes/No)

Project is listed on the National Register of Historic Places.

(Yes/No)

National Register No.:

A copy of the Scope of Work for the above referenced project, or contract special provisions detailing this portion of the work and is attached:

(Detailed Scope of work is required. For easy review please attach project name, scope, and photos)

Owner/Owner’s Representative for Above Project:

Owner Contact Name:

Owner Telephone Number:

Additional persons with knowledge of project:

Contract Award Date:

Date Above Project Was Accepted by Owner (Completion Date):

Procurement #11568R at Cape Blanco State Park (Roofing Phase) Historic Preservation Contractor Qualifying Work Experience Reference Form General Contractor (page 2 of 3)

Name of proposed Historic Preservation General Contractor (Bidder):

Bidder must provide verifiable references for projects on which the contractor has successfully completed, (the general contractor) within the last ten (10) years, historic preservation work on a minimum of three (3) historic buildings listed on the National Register of Historic Places. Total contract must meet or exceed stated minimums to qualify.

Historic Building Name:

Total Contract Price at Completion including Change Orders:

Project satisfies contractor’s required Special Historic Qualifications? (Yes/No)

Project is listed on the National Register of Historic Places.

(Yes/No)

National Register No.:

A copy of the Scope of Work for the above referenced project, or contract special provisions detailing this portion of the work and is attached:

Owner/Owner’s Representative for Above Project:

Contract Award Date:

Date Above Project Was Accepted by Owner (Completion Date):

Procurement #11568R at Cape Blanco State Park (Roofing Phase) Historic Preservation Contractor Qualifying Work Experience Reference Form General Contractor (page 3 of 3)

Name of proposed Historic Preservation General Contractor (Bidder):

Bidder must provide verifiable references for projects on which the contractor has successfully completed, (the general contractor) within the last ten (10) years, historic preservation work on a minimum of three (3) historic buildings listed on the National Register of Historic Places. Total contract must meet or exceed stated minimums to qualify.

Historic Building Name:

Total Contract Price at Completion including Change Orders:

Project satisfies contractor’s required Special Historic Qualifications? (Yes/No)

Project is listed on the National Register of Historic Places.

(Yes/No)

National Register No.:

A copy of the Scope of Work for the above referenced project, or contract special provisions detailing this portion of the work and is attached:

Owner/Owner’s Representative for Above Project:

Contract Award Date:

Date Above Project Was Accepted by Owner (Completion Date):