Crossroads Renovation - Application to Prequalify.docx

FAIRFAX COUNTY

DEPARTMENT OF PUBLIC WORKS AND ENVIRONMENTAL SERVICES

APPLICATION FOR PREQUALIFICATION

FAIRFAX COUNTY CROSSROADS RENOVATION

PROJECT No. HS-000050-001

A. This page shall be the cover page for the Application submitted.

B. All required attachments and any additional information requested in this Solicitation must be attached herein.

Attachments:

F. Safety Program (Forms and Supplemental Information) G. Fairfax County Construction Safety Resolution

Acknowledge receipt of addendum below if applicable (initial and date):

Submitted by:

Applicant Name: ____________________________________________________

Address: __________________________________________________________

City/State/Zip Code: _ ________________________________________________

Signed by: _________________________________________________________

Printed name and title: ________________________________________________

Telephone No: ______________________________________________________

Signing Applicant Representative Email: ___________________________________

Alternative Email Account (Monitored Daily): ________________________________

ATTACHMENT A

APPLICANT'S PREQUALIFICATION STATEMENT

CROSSROADS RENOVATION

Submitted By: ________________________________________________________

Applicant Name and Address: ____________________________________________

Applicant telephone No.: (____) _____________ Fax No.: (____) __________________

Applicant's 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: ______________ Tel.: ______________

Email:__________________________

Indicate if: Corporation Sole Proprietor Partnership

Joint Venture Other (Indicate) __________________

The Applicant may attach additional information deemed appropriate to respond. Do not attach additional information irrelevant to the response.

1. Organization

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:

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 applicant'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 applicant 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.

2. Judgments

A. Has the applicant 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?

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 Applicant 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 Applicant 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).

Yes _____ No ______

D. Has the Applicant 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).

Yes _____ No ______

E. Has the Owner or Owner’s Agent ever taken steps to complete contract work, which was the Applicants own responsibility? If yes, indicate date(s), project(s), owner or A/E references, and reason(s).

Yes _____ No ______

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

Yes _____ No ______

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

Yes _____ No ______

H. Has the Applicant 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).

Yes _____ No ______

I. Has the Applicant 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).

Yes _____ No ______

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

Yes _____ No ______

4. Convictions

Has the applicant 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.

Yes _____ No ______

5. Debarment

Is the applicant 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?

Yes _____ No ______

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

5. _____________________________________________________________

B. MAJOR SUBCONTRACTORS:

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

5. _____________________________________________________________

C. OWNERS:

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

5. _____________________________________________________________

7. Financial

A. Does any individual, company or corporation own a 10% or more interest in the outstanding shares of the capital stock of the Applicant?

Yes _____ No ______

If yes, list the name and percent interest of ownership held in the Applicant.

B. Audited financial statements for the Applicant’s previous three fiscal years may be required. These financial statements, if requested, shall include a complete report of Applicant’s financial resources, liabilities, equipment, and personnel.

C. Is the Applicant currently a debtor in any bankruptcy case or has been in bankruptcy at anytime during the previous five (5) years? If yes, state date(s), and reason(s).

Yes _____ No ______

8. Workers Compensation Experience

List your Experience Modification Rate (EMR) for workers compensation and OSHA incidence rate for the past three years:

9. Surety and Insurance

A. Provide documentation from your Surety identifying Applicant’s total bonding capacity, individual job bonding capacity, and maximum the Applicant can be bonded on a single project. Provide Surety Statement as outlined in Attachment E.

B. List all other sureties (name and address) that have written bonds for the Applicant during the last five years.

C. Provide the following information:

Average annual contract volume for the past 5 years $ _____________

Total value of work in progress or under contract $ _____________

D. Has any surety company made a payment on Applicant’s behalf as a result of default, to satisfy any claims made against a performance or payment bond in connection with any construction project during the previous five (5) years? If yes, state date(s), project(s), and reasons.

Yes _____ No ______

E. Has any insurance carrier, for any form of insurance, refused to renew insurance policy for your firm? If yes, state date(s), and reason(s).

Yes _____ No ______

10. Confidential and Proprietary Information

Initial here ____ if the applicant requests that all information submitted as part of this prequalification process be considered a trade secret or as proprietary information subject to the provisions of subsection D of § 11-52, Code of Virginia.

ATTACHMENT B

PROJECT EXPERIENCE

Applicant shall demonstrate conformance to the experience requirements of this solicitation and provide the following:

1. On a separate sheet(s), list all construction projects your organization has in progress, giving the name of project, scope, owner, design engineer/architect, contract amount, percent complete and scheduled completion date.

2. On a separate sheet(s), list all projects similar to the work herein being performed or performed during the past ten (10) years, giving the name of project, owner, design engineer/architect, contract amount, and date of completion and project scope description. Please verify prior to submission that all contact information is accurate and current.

3. Provide on the following pages (attachments B1, B2, B3, etc.) the details of at least three (3) similar construction projects for governmental, institutional, or private owners for which the Applicant has acted as a General Contractor and completed within the past seven (7) years with original contract values of $15,000,000 (USD) or more.

ATTACHMENT B1

SIMILAR PROJECTS

PROJECT 1

DETAILS OF PROJECT

1. Applicant Name: _____________________________________________

Project Manager Name: __________________________________

Superintendent Name: ___________________________________

Telephone Number: ( )

4. Engineer/Architect: ___________________________________________

Address: ______________________________________________

Contact Person: ________________________________________

Telephone Number: ( )

5. Contract Dates - Attach additional information if project was not on schedule.

Started: __________

Original Contractual Completion:

Final Contractual Completion:

Actual Completion:

7. Original Contract Value $

Final Contract Value $

Value of Change Orders to Date $

Value of Outstanding Claims to Date $

8. Name of Bonding Company ____________

Address:

Contact Person:

Telephone Number: ( )

ATTACHMENT B2

PROJECT 2

DETAILS OF PROJECT

1. Applicant Name: _____________________________________________

Project Manager Name: __________________________________

Superintendent Name: ___________________________________

4. Engineer/Architect: ___________________________________________

Address: ______________________________________________

Contact Person: ________________________________________

Telephone Number: ( )

5. Contract Dates - Attach additional information if project was not on schedule.

Started: __________

Original Contractual Completion:

Final Contractual Completion:

Actual Completion:

7. Original Contract Value $

Final Contract Value $

Value of Change Orders to Date $

Value of Outstanding Claims to Date $

8. Name of Bonding Company

Address:

Contact Person:

Telephone Number: ( )

ATTACHMENT B3

PROJECT 3

DETAILS OF PROJECT

1. Applicant Name: _____________________________________________

Project Manager Name: __________________________________

Superintendent Name: __________________________________

Contact Person: ________________________________________

Telephone Number: ( )

4. Engineer/Architect: ___________________________________________

Address: ______________________________________________

Contact Person:

Telephone Number ( )

5. Contract Dates - Attach additional information if project was not on schedule.

Started: __________

Original Contractual Completion:

Final Contractual Completion:

Actual Completion:

7. Original Contract Value $

Final Contract Value $

Value of Change Orders to Date $

Value of Outstanding Claims to Date $

8. Name of Bonding Company

Address:

Contact Person:

Telephone Number ( )

ATTACHMENT C

KEY PERSONNEL

1. Provide information about the experience of key personnel of the Applicant that will be associated with this project. The information shall include name, title, intended assignment, years of construction experience, last employer, last position, and experience on similar projects.

2. Applicant must also provide the percentage of time the key personnel will dedicate to the project.

ATTACHMENT D

VIRGINIA CLASS A CONTRACTOR’S LICENSE STATEMENT

Provide a Statement of applicant's ability to possess a Virginia Class A Contractor's License prior to bidding, and a commitment to ensure that affected subcontractors obtain applicable Virginia Contractor's Licenses.

ATTACHMENT E

SUGGESTED SURETY STATEMENT

REFERENCE: APPLICATION FOR PRE-QUALIFICATION

CROSSROADS RENOVATION

(Name of Applicant) has been a client of (name of Surety Company) for over (______) years. During that time, we have supported this firm in their pursuit of projects in the $________ range and total programs in excess of $_____________. We are prepared to provide Bid, Performance, and Payment Bonds on the aforementioned project, provided (name of Applicant) is awarded the contract.

We also possess certificates of authority as an acceptable surety authorized to do business in the Commonwealth of Virginia as published annually in the Federal Register, Department of Treasurer, Fiscal Service, Department Circular 570.

Sincerely, Attorney-In-Fact (Name of Surety Company)

Name of Surety

Signature

Typed Signature

Date

Address

Telephone

ATTACHMENT F

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?

Yes No _____

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

Yes No _____

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?

Yes No _____

If yes, provide detail on separate sheet.

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

Provide detail on separate sheet.

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

Provide detail on separate sheet.

Fairfax County Crossroads Renovation Prequalification Application

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

Provide detail on separate sheet.

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

Provide detail on separate sheet.

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?

Provide detail on separate sheet.

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)? See attachment G, Fairfax County Construction Safety Resolution.

Yes No _____

If yes, provide detail on separate 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.

Fairfax County Crossroads Renovation Pre-Qualification Application

ATTACHMENT G

All bidders will be required to meet Fairfax County Safety Resolution at the time of bid. The current Fairfax County Safety Resolution is provided below.

FAIRFAX COUNTY CONSTRUCTION SAFETY RESOLUTION

The Contractor shall comply with the resolution adopted by the Fairfax County Board of Supervisors on December 8, 2003, as amended:

A. It shall be required that each bid submitted to the County for a contract for construction, alteration, and/or repairs, including painting or decorating of a building, highway, street, bridge, sidewalk, culvert, sewer, excavation, grading, or any other construction, include a list of all the following actions which have become final in the three years prior to the bid submission:

1. Willful violations, violations for failure to abate, or repeated violations, for which the bidder was cited by (a) the United States Occupational Safety and Health Administration; (b) the Virginia Occupational Safety and Health Administration; or (c) the occupational safety and health plan for any other public jurisdiction; or

2. Three (3) or more serious construction safety violations for which the bidder was cited by the (a) United States Occupational Safety and Health Administration; or (b) the Virginia Occupational Safety and Health Administration; or (c) the occupational safety and health plan from any other public jurisdiction.

3. Termination of a contract between the contractor and any public entity by their purchasing agent or his designee for safety violations.

B. If the bidder has not received or been the subject of any such violations referenced in paragraph A in the three (3) years prior to the bid submission, then the bidder shall so indicate by certification on the bid form entitled Certification of Safety Violations. The bidder will also indicate on this form each state in which work was performed in the three (3) years prior to the bid submission.

1. No bidder or contractor may bid on a County construction contract who has been the subject of any citations for the type and number of violations listed in aforementioned paragraph A, which have become final within the three (3) years prior to the bid submission.

0. Notwithstanding the language of paragraph C, above, any bidder or contractor who has been the subject of a violation, as described in paragraph A.1, which has become final in the three (3) years prior to the bid submission, may bid, if the bidder or contractor meets the eligibility criteria set forth in paragraph E, below.

2. Notwithstanding the language of paragraph C, above, any bidder or contractor who has been the subject of the type and number of violations as described in paragraph A.2, which have become final within three (3) years prior to bid submission, may bid, if the bidder or contractor meets the eligibility criteria in paragraph E, below.

3. Notwithstanding the language of paragraph C, above, any bidder or contractor who has previously been terminated from a public contract, as described in paragraph A.3, within three (3) years prior to the bid submission, may bid, if the bidder or contractor meets the eligibility criteria in paragraph E, below.

D. Prior to bidding on a project, under the provisions of paragraph C above, a contractor may request that a determination be made by the County's Purchasing Agent or designee, regarding their eligibility to submit a bid on a contract under the terms of this resolution. However, this request for determination and any subsequent adjudication process must be completed prior to submitting a bid on any project and the request for determination must be received by the County's Purchasing Agent or designee no later than twenty-one (21) days before bids are due unless otherwise stated in the Solicitation. A notice of the bidder’s request for determination of eligibility will be posted publicly for comments by any interested party. The bidder’s request for determination of eligibility and all supporting documentation provided by the bidder to the County in support of its request shall be open to the inspection of any interested person, firm or corporation in accordance with the requirements of Fairfax County Purchasing Resolution and Virginia Freedom of Information Act.

E. At the request of the Purchasing Agent or designee, the County Risk Manager shall evaluate a contractor's eligibility. Contractors may be subject to a special audit of their safety records as required. The criteria used by the Risk Manager in evaluating contractor’s eligibility shall include but not be limited to the following:

1. Corrective action taken by a bidder or contractor to prevent the recurrence of safety violations.

2. Days Away from Work Incident Rate for the past three (3) years.

3. Summary of Work-Related Injuries and Illnesses/Incident Rate for the past three (3) years.

4. Worker’s Compensation Experience Modification Rating for the past three (3) years.

5. Fatality record for the past five (5) years.

6. Detailed information regarding the firm’s safety program including but not limited to a Safety and Health plan and qualifications of the safety personnel.

7. Verification that management staff directly in charge of projects that experienced safety violations listed in aforementioned paragraph A will not be involved in the County project.

8. Incorporation of safety and health related issues into their new employee orientation programs.

9. Incorporation of work safety as a part of an employee's performance evaluation.

10. Support of safety related matters by senior/corporate management. Does the firm have a safety policy statement signed by a member of senior/corporate management?

11. Designation of a full time Safety Manager. Does this person report to a high level, authoritative position within the Company?

12. Frequency and type of safety inspections conducted at work sites.

13. The number and type of safety training programs conducted for employees.

14. Frequency of safety "tailgate meetings" conducted by the firm.

15. Designation of an active safety committee, frequency of their meetings and list of members of the committee.

16. Active membership in a recognized construction safety organization in the Washington Metropolitan area, or in the state of contractor's domicile.

1. The determination of eligibility rendered by the Purchasing Agent or his designee shall be final unless it is appealed in accordance with the provisions of the solicitation or the Fairfax County Purchasing Resolution.

G. It shall be a condition of each County construction contract, as discussed above, that no contractor or subcontractor contracting for any part of the contract work shall require any laborer, mechanic, or other person employed in the performance of the contract to work in surroundings or under working conditions which are hazardous or dangerous to his safety, as determined under construction safety standards promulgated by the U.S. Department of Labor or the Virginia Department of Labor and Industry.

H. The contractor awarded a County construction contract shall certify in writing that they will not knowingly, willfully, or recklessly employ or contract with any person, company, corporation, or any other entity for services pursuant to that contract if such person, company, corporation, or other entity could not have been awarded such contract due to the restrictions in paragraph C, above.

I. The contractor shall also certify in writing that all safety related information provided in accordance with the Safety Resolution and contract requirements are complete, accurate and truthful.

J. The failure to provide information requested pursuant to this Resolution or the failure to conform to the certification requirements of this Resolution shall be grounds for disqualifying a prospective bidder.

K. The County may impose the following sanctions upon a contractor who willfully submits any false or misleading certification or information regarding material facts in connection with submissions pursuant to this Resolution, or willfully omits any certification or information regarding material facts in connection with submissions pursuant to this Resolution. The term willful shall include intentional or reckless acts or omissions.

(1) Disqualify the prospective bidder from bidding a contract.

(2) Debar the contractor from bidding future contracts for a period not to exceed three years.

(3) Terminate the contract awarded to the bidder after providing notice and opportunity to be heard.

ATTACHMENT H

QUALITY CONTROL PROGRAM

Describe your Quality Control and Quality Assurance Programs and its implementation plan. It is understood that the Quality Control Plan, as submitted herewith, shall be in effect for the duration of the entire Project should it be awarded to the applicant named herein:

ATTACHMENT I

AFFIDAVIT OF ACCURACY

The undersigned swears or affirms under the penalty of perjury and upon personal knowledge that the contents of the Application for Pre-Qualification are true and correct.

The undersigned swears or affirms under the penalty of perjury that the contractor, its agents, servants and/or employees, to the best of his/her knowledge and belief, have not in any way colluded with anyone for and on behalf of the contractor an unfair advantage over others, nor have they colluded with anyone for and on behalf of the Contractor, or themselves, to gain any favoritism in the award of any contract resulting from this bid.

NAME OF APPLICANT

REPRESENTATIVE/TITLE

(SIGNATURE)

ADDRESS

TELEPHONE NUMBER

DATE:

NOTARY SEAL: