Dear Contractor:
The City of Gig Harbor invites you to apply to be placed on the Small Works Roster. Please complete and return the Application. Your materials should indicate your specialties and recent projects. E-mail or mail your materials as follows.
E-mail: whitakerm@cityofgigharbor.net
City of
Attention
Maureen Whitaker,
FAX: 253.853.7597
Phone: 253.853.7618
Qualifications. The City of Gig Harbor seeks companies that:
□ Maintain insurance (as specified on the Application);
□ Have been in continuous business at least one year prior to Application;
□ Have a responsible financial history;
□ Have a strong safety rating.
Accepted Applications remain on the Roster without expiration. The City of Gig Harbor may contact you in two years to refresh your information. Rejected Applications are discarded by the City of Gig Harbor, although companies that are rejected may submit a new Application at a later date. The City of Gig Harbor retains that right to reject, remove or suspect a company at any time, based on the City’s opinion of performance, responsibility, or failure to respond to inquiries for renewal data. We will contact you by e-mail to confirm the status of your application after the processing has been completed.
We appreciate your interest.
Maureen Whitaker
City of
Small Works Roster
Return this application by
mail, E-mail, or fax to:
Maureen Whitaker,
City of
Phone: 253.853.7618
Fax: 253.853.7597
Company Name:
_______________________________________________________________
Owner Name:
_________________________________________________________________
Contact Person:
________________________________________________________________
Contact Person’s Title:
___________________________________________________________
Mailing Address:
_______________________________________________________________
Physical Address:
______________________________________________________________
Office Phone: __________________________________________________________________
Contact Person Cell Phone:
______________________________________________________
Contact Person Pager: ____________________________ Fax:
_________________________
E-mail: _______________________________________________________________________
Company Web Address:
_________________________________________________________
Business Classification (specify date established as
appropriate):
You do not need to have a formal government
certification to check these boxes (Self-designated).
□ Woman Owned □
Minority Owned □
Federal Disadvantaged Business
□ Individual: _____________________________________
□ Partnership: _____________________________________
□ Corporation: _____________________________________
Note: A State Contractor or Specialty
License is a minimum requirement to submit an application.
UBI Number: __________________ Federal Tax ID Number:
___________________________
L&I License Expiration date: (For office use only):
_____________________________________
Would you like your company to be included on our “Emergency Response List”? Yes: □ No: □
If
Yes, Emergency Contact Phone # ______________________
MINIMUM QUALIFICATIONS
Minimum qualifications must be me unless specifically
waived by the City of
reserves the right to reject at any time, including
after an initial inclusion on the Roster, if the applicant is not responsible
in the opinion of the City.
□ Do you
have a current valid Contractor’s license and will you maintain the license
while on the Roster? Yes:
____ No: ____
□ Have
you successfully finished a public-agency construction project?
Yes:
____ No: ____
□ Have you been in business at least 3 years without
interruption:
Yes: ____ No:
____
□ Do you
have a strong claims history, strong safety record (below 1.0 on the L&I
rating), and strong financial history?
Yes: ____ No: ____
INSURANCE REQUIREMENTS
Applicant must have the
following minimum insurance coverage in place at the time of application.
General
liability insurance of at least $1,000,000 per occurrence;
$1,000,000
aggregate, Combined Single Limit (CSL);
Automobile
liability of at least $1,000,000 per accident CSL; and
Ability to name the City of
Gig Harbor as an Additional Named Insured by providing a separate endorsement.
Do you currently maintain the minimum required insurance
coverage? Yes: ____ No: ____
If no, describe any differences to the specified coverage
amounts: ________________________
Are there any current claims that are pending against this
insurance policy: Yes: ____ No: ____
CONTRACTOR FINANCIAL HISTORY
During the past five years, has the Contractor been involved
in any:
- Construction
bond forfeiture; Yes:
____ No: ____
- Construction
litigation; or Yes:
____ No: ____
- Claims
exceeding ten percent of the contract price? Yes: ____ No: ____
CONTRACTOR HISTORY
Provide dates for the periods within the past ten years that
the Contractor:
Has not been an active Contractor:
_______________________________ or N/A: ____
Has not been a licensed Contractor:
______________________________ or N/A:
____
Has been in bankruptcy, reorganization or receivership:
_______________ or N/A: ____
Has owner been convicted of a felony:
_____________________________ or N/A: ____
Has the company ever been disqualified by any public agency
from participation in public contracts.
Yes:____ No: ____ If yes,
explain:______________________________________
CONTRACTOR SAFETY EXPERIENCE
□ SOLE PROPRIETOR:
This section will not apply to sole proprietors. Check box if you are a sole proprietor that
does not have employees and skip this section.
List Contractor’s
compensation Experience Modification Rate for the three most recent years. If score is above 1.0 are subject to
rejection. This rate is given to you
every year from Labor & Industries.
Your company receives a multi-page report each year, with these rates
indicated. If you don’t know this rate,
call L&I or check their website at https://fortress.wa.gov/lni/crpsi/. If you need assistance, call Maureen
Whitaker at City of Gig Harbor at 253.853.7618.
2005_______ 2006_______
2007_______
Please use the most recent year’s
OSHA log to provide the following:
- Number of lost workday cases:
_______________
- Number of fatalities:
________________________
Does the Contractor conduct project safety inspections? Yes: _____ No: _____
Does the Contractor have a written Safety Program? Yes: _____ No: _____
Does the Contractor have a safety orientation program for new
hires? Yes: _____ No: _____
How frequently do on-site crews hold safety meetings? Yes: _____ No: _____
List 3 jobs performed for a public agency. Include private jobs only if needed to
fulfill the list. Those companies that
do not yet have 3 public jobs may be rejected.
Name: of Project #1: ___________________________________________________________
Agency/Owner’s Name:
__________________________________________________________
Contact Name and Phone:
_______________________________________________________
Prime Contractor and Phone: (if not your firm):
________________________________________
Dollar amount of your portion of the work: ___________________________________________
Month and year project completed:
_________________________________________________
Name: of Project #2: ___________________________________________________________
Agency/Owner’s Name:
__________________________________________________________
Contact Name and Phone:
_______________________________________________________
Prime Contractor and Phone: (if not your firm):
________________________________________
Dollar amount of your portion of the work: ___________________________________________
Month and year project completed:
_________________________________________________
Name: of Project #3: ___________________________________________________________
Agency/Owner’s Name:
__________________________________________________________
Contact Name and Phone:
_______________________________________________________
Prime Contractor and Phone: (if not your firm):
________________________________________
Dollar amount of your portion of the work: ___________________________________________
Month and year project completed:
_________________________________________________
Company Signature: ___________________________________________________________
I swear under penalty of
perjury that the above and attached information is correct and there are no
know personal and/or organization conflicts of interest which are prohibited by
law.
City Authorizing Signature:
Maureen Whitaker,
The following identifies your
company’s specialties. Mark any and all
services you perform. Provide comments
if desired:
Demolition:
q
Property Refuse
Removal/Disposal
q
Building
Demolition
q
Building/Structure
Moving
q
Asphalt
Demolition
q
Structure
Demolition
q
Hazardous
Material Removal/Abatement
q
Petroleum
Contaminated Soil Removal
Vegetation:
q
Tree
Trimming/Removal
q
Stump
Grinding/Removal
q
Vegetation
Disposal
q
Vegetation
Spraying
q
Mechanical Brush
Control
q
Reforestation
q
Tree
Transplanting
Earthwork:
q
Excavation and
Trucking
q
Grading
q
Erosion Control
q
Dump Truck
Hauling
q
Horizontal
Boring/Drilling
q
Landslide Repair
q
Trenchless Pipe
Installation
q
Water Well
Drilling
q
Well
Rehabilitation
q
Pump Service Work
q
Drilled Shafts
Drainage:
q
Storm Drainage Construction
q
Storm Drainage Cleaning
Sanitary Sewers:
q
Side Service
Construction
q
Temporary
Sanitary Sewer Bypass Pumping
q
Repairing
Sanitary Sewers – Internally
q
Sanitary Sewer
Pump Station
q
Sanitary Sewer
Television Inspection
q
Sanitary Sewer
Cleaning
q
Sewer Grouting
and Sealing
q
Hot Tapping
(Sewer Taps)
q
Manhole
Rehabilitation
Roadway
Work:
q
Concrete
Sidewalks/Curbs/Gutters/Driveways
q
Mud-Jacking
q
Asphalt and
Concrete Pavement
q
Asphalt Chip
Seals
q
Slurry Seal
q
q
Rockeries
q
Gravity Block
Walls
q
Pavement Repair
q
Manhole and Valve
Adjustments
q
Roadway
Construction
q
Thermoplastic
Pavement Markings
q
Paint Striping
q
Guardrail
Installation
q
Street Sweeping
q
Raised Pavement Markings
q
Traffic Sign
Installation
q
Asphalt Seal
Coating
q
Asphalt Crack
Filling
q
Concrete
Retaining Walls
q
Concrete
Barrier/Permanent & Temporary
q
Concrete
Recycling
q
Waterproofing/Coating/Sealants
q
Snow Removal
Water/Treatment:
q
Location
Underground Facilities
q
Leak Detection
Service
q
Watermain
Construction
q
Fire Hydrant
Installation
q
Water Treatment
Systems
q
Hot Tapping
(Watermain Construction)
q
Water Tank
Painting/Fabrication
q
Water Pump
Station
Electrical/Telephone:
q
Electrical
Inspection
q
Electrical
Construction