Fillable Form 868 Prequalification Application (City of Grants Pass)

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Form 868 Prequalification Application (City of Grants Pass)

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City of Grants Pass
CONTRACTOR’S
PREQUALIFICATION
APPLICATION
Equipment and Experience Questionnaire
Adopted by the Department of Administrative Services
Application of:
Submittal Date:
Individual Co-Partnership
Corporation
Joint Venture Member of Joint Venture
Address to which all applicant’s correspondence is to be mailed:
Mailing Address City & State Zip Code
Business Phone Number Cell Phone Number Fax Number
Contact Name Email Address
This Prequalification Application is submitted for
the following purpose: (Check One)
This is a prequalification application for
such period of time as designated by the
mandatory prequalification rules adopted
by the Public Contracting Agency.
This is a prequalification application for
the following:
Name of Project
101 Northwest A Street -- Grants Pass, Oregon 97526 -- (541) 450-6060 -- Fax (541) 476-9218 -- www.grantspassoregon.gov
City of Grants Pass Contractor’s Prequalification Application Revised 02/2017
Page 1 of 17
This prequalification application is subject to the provisions of Ordinance #4752, adopted by the Council of the City of Grants
Pass on December 2, 1992 and Ordinance 5517/Resolution 5682 adopted by the Council of the City of Grants Pass on June 2, 2010.
This space for Engineering use only.
City of Grants Pass
Contractor’s Prequalification Application
Page 2 of 17
Revised 02/2017
PREQUALIFICATION REQUIREMENTS
REQUIREMENTS: To be prequalified to work on projects involving the construction of public facilities, a
Contractor must meet the following requirements:
1. EXPERIENCE: The Contractor, or the Contractor’s Supervisor on the project, must have twelve months
experience working as a Contractor or Supervisor on comparable public projects (e.g.
monetary value, complexity)with the same materials as those required by City standards
(i.e., ductile iron pipe for water lines) or comparable competence as determined by the
City Manager.
2.
INSPECTION
SUBSTITUTION:
This criteria can be substituted with a City approved schedule for inspection of the
project by a licensed engineer with a civil or structural background. The costs of this
additional inspection shall be the joint responsibility of the Contractor, Supervisor, and
Developer, not the City.
3. SAFETY: The Contractor or Supervisor must have an OSHA approved, written safety program with
proof of monthly safety meetings for the twelve months preceding a bid.
4.
CURRENT OREGON
CONTRACTOR LICENSE:
The Contractor shall have a current Oregon General Contractor’s License.
5. CURRENT CITY
BUSINESS TAX:
The Contractor shall have a current City Business Tax.
6. INSURANCE BONDS The Contractor shall have adequate current insurance bonds to cover the contract
amount (if no performance bond.) Liability insurance requirements shall be set forth by
resolution. The City requires minimum insurance limits of $1 million per claim with a $2
million aggregate. (Ord. 5517/Res. 5682 §2,2010)
7. WORKER’S
COMPENSATION:
All employees must be covered by Oregon Worker’s Compensation.
8. ON-SITE
SUPERVISION:
A crew leader, with at least twelve months experience, must be on-site during all work.
This can be eliminated if the Contractor or Supervisor, who satisfies item 15 of this
application, is on-site during all work.
9. TRAINING
SESSIONS:
To qualify for prequalification, the Contractor must agree to attend a City training
program prior to the awarding of any bid. The training program will provide information
on working on projects within the right-of-way, and review City standards and
requirements.
10. CONSTRUCTION AND
SAFETY STANDARDS:
The Contractor shall continuously abide by the terms of the contract, the City approved
construction drawings, and standard City specifications for installation of all public
facilities within the jurisdiction of the City of Grants Pass. The Contractor has the
obligation to be familiar with and comply with all applicable City, State, and Federal
construction and safety standards, and applicable laws. Ignorance of these standards of
laws is not an excuse for noncompliance.
City of Grants Pass
Contractor’s Prequalification Application
Page 3 of 17
Revised 02/2017
DISQUALIFICATIONS AND
RESTRICTIONS:
A Contractor may be disqualified or restricted from working on projects
involving the construction of public facilities if it is found that the Contractor,
or any other agent or employee, fails to meet, or has misrepresented the
Contractor’s compliance with, the City’s prequalification requirements.
1. HEARING: When a Contractor is alleged to be in violation or non-compliance with any of
the prequalification requirements, a hearing will be held by the Community
Development Director, or a designee as hearings officer, to review the violation
or non-compliance. A notice of the hearing, and a brief statement of the
allegation, shall be mailed to the last known address of the Contractor no less
than seven days prior to the hearing. At the hearing, the hearings officer shall
provide an opportunity for the Contractor to be advised of the basis for the
allegation, and to provide evidence to refute or mitigate the allegation. The
hearings officer shall make a decision within five days of the hearing, and shall
cause the decision to be mailed to the last known address of the Contractor
within four days of the decision.
2. PERIOD OF
DISQUALIFICATION
OR RESTRICTIONS:
A Contractor found in violation or non-compliance shall be disqualified or
restricted by the hearings officer regarding the construction of public facilities
for a specified period of time based upon the seriousness of the violation or
non-compliance. Disqualification or restriction imposed for a first offense shall
be no longer than twelve months. Subsequent disqualifications or restrictions
may exceed twelve months, but shall not exceed twenty-four months. A period
of disqualification may be followed by a period of restrictions so long as the
total period does not exceed the above stated time limitations.
3. RESTRICTIONS: When the hearings officer determines that a violation or non-compliance with
the City’s prequalification requirements should result in restrictions instead of
disqualification, the hearings officer shall state the reasons for mitigation in the
decision. A restriction may include the imposition of additional conditions and
requirements, including but not limited to, providing a civil or structural
engineer to provide full-time inspections of construction, said costs being
the responsibility of the Contractor.
4. APPEAL TO
CITY MANAGER:
A decision by the hearings officer to disqualify or restrict a Contractor may be
appealed to the City Manager by filing a written notice of appeal within
fourteen days of the decision by the hearings officer. The City Manager shall
conduct a hearing within thirty days of the notice to appeal. A notice of the
hearing shall be mailed to the last known address of the Contractor no less
than seven days prior to the hearing. At the hearing, the City Manager shall
provide an opportunity for the Contractor to challenge the disqualification or
imposition of restrictions. The City Manager shall make a decision within five
days of the hearing, and shall cause the decision to be mailed to the last known
address of the Contractor within four days of the decision. The City Manager
may affirm, reverse, or modify the decision of the hearings officer.
City of Grants Pass
Contractor’s Prequalification Application
Page 4 of 17
Revised 02/2017
The decision of the City Manager shall comply with the PERIOD OF
DISQUALIFICATION OR RESTRICTION and RESTRICTIONS provisions noted
above. Modification of the hearings officer’s decision may include but is not
limited to:
A. Increasing or decreasing the quantity or quality of restrictions imposed.
B. Changing a disqualification to a restriction.
C. Changing a restriction to a disqualification.
A. Increasing or decreasing the quantity or quality of restrictions imposed.
B. Changing a disqualification to a restriction.
C. Changing a restriction to a disqualification.
6. INTERIM EFFECTIVENESS A decision of the hearings officer shall be effective immediately, and shall
OF DISQUALIFICATION
remain effective unless or until it is affirmed, reversed, or modified by the
OR RESTRICTION:
City Manager. A decision of the City Manager shall be effective immediately,
and shall remain effective unless or until it is affirmed, reversed, or modified
by the City Council.
5. APPEAL TO
CITY COUNCIL:
A decision by the City Manager to disqualify or restrict a Contractor may be
appealed to the City Council by filing a written notice of appeal within fourteen
days of the decision by the City Manager. The City Council shall conduct a
hearing within thirty days of the notice to appeal. A notice of the hearing shall
be mailed to the last known address of the Contractor no less than seven days
prior to the hearing.
At the hearing, the City Council shall provide an opportunity for the Contractor
to challenge the disqualification or imposition of restrictions. The City Council
shall make a decision within fourteen days of the hearing, and shall cause the
decision to be mailed to the last known address of the Contractor within four
days of the decision. The City Council may affirm, reverse, or modify the
decision of the City Manager. The decision of the City Council shall comply with
the PERIOD OF DISQUALIFICATION OR RESTICTION and RESTRICTIONS provisions
noted above. Modification of the Manager’s decision may include but is not
limited to:
City of Grants Pass
Contractor’s Prequalification Application
Page 5 of 17
Revised 02/2017
INSTRUCTIONS
Introductory Statement:
In accordance with the statutes of the State of Oregon, every public contracting agency contemplating receiving bids
for, and awarding any contract for, a public improvement may require any prospective bidder to submit a full and
complete statement concerning his/her equipment and experience in constructing public improvements.
The application and questionnaire forms, which are bound herewith, comply with the requirements of public contracting
rules and must be used in determining the qualifications of prospective bidders and in assigning limits as to the size and
kinds of projects for which the prospective bidder may submit bids. The applicant should use care and integrity in
preparing this information. The public contracting agency may make independent inquiries concerning the Contractor’s
past performance and/or capabilities.
Manner of Preparing and Completing Forms:
This application shall include equipment and experience information for only the specific single business, organization,
or entity which is applying for prequalification, and which would be the signatory on a contract with the public
contracting agency.
It shall be the responsibility of the applicant to return all pages, whether applicable or not. Failure to do so may be
grounds for rejection.
The entire application shall be completed, with all answers and entries specific and complete in detail.
The prequalification application shall be signed by the applicant and sworn to as the form indicates. The signatory of the
statement guarantees the truth and accuracy of all statements, and of all answers to questions.
Use of Attachments:
Schedules, reports, and other forms of prequalification statement may be used as attachments to the prescribed form,
provided that the information contained therein specifically includes the information required by this form.
Place of Submission:
Prequalification applications shall be submitted to the designated officer or public contracting agency.
Time of Submission:
Each Public Contracting Agency may have specific time requirements for filing applications. The applicant should check
with the designated officer of the applicable agency for submission time.
Appeal Due to Denial or Revocation of Prequalification:
In case a Contractor’s application for prequalification is denied, or in case an existing prequalification is revoked, the
Contractor may appeal the denial or revocation in accordance with the rules adopted by the Department of
Administrative Services, or the appropriate local contract review board.
City of Grants Pass
Contractor’s Prequalification Application
Page 6 of 17
Revised 02/2017
Notification of Action Taken:
The applicant will be notified, in writing, of the action on the application. If approved, the applicant will then be allowed
to bid on such projects as are within the limits of the size and kind of work for which he/she has been declared qualified.
Period During Which a Qualified Bidder Remains Qualified:
A prospective bidder, who has been notified of prequalification for projects of a given size and kind, will usually remain
qualified until the date specified in the notification. The public contracting agency may limit prequalification approval to
individual public improvement projects. Unless such bidder is otherwise notified by the public body, he/she will be
permitted to submit bids for any and all projects of said kind and size for which bids are to be received. The public body
may, from time to time, require new or revised action on an application. A prequalification may be revoked under
the provisions of ORS 279.039.
Changes:
Requests for revision of the prequalification standing of any prospective bidder will be considered whenever the bidder
can make a showing of materially improved ability, but not more often than once in three months. Each such request
must be accompanied by a new prequalification application.
With or without a request from the prequalified bidder, the prequalification limitation on class of work or size of project
may be reviewed and increased or decreased as found appropriate. The prequalified prospective bidder will be notified
in writing of any such revision.
Confidential Information:
The information furnished in the prequalification application will be treated as confidential information if so requested
by the applicant. If so requested in item 12 of the application, contents of the application will not be disclosed to the
public, except upon the written order of the person or persons furnishing the same, or upon an appropriate order of a
court of competent jurisdiction.
Joint Venture:
A public contracting agency may adopt special requirements concerning joint ventures. Before submitting a joint
venture application, a prospective bidder should ascertain if special instructions are applicable, and obtain them from
the designated public officer.
Minority Contractors:
Do not fill in item 8 of the application unless required by the public contracting agency.
City of Grants Pass
Contractor’s Prequalification Application
Page 7 of 17
Revised 02/2017
1
Indicate licenses and license numbers held as required by Oregon statutes:
CCB License Number:
LCB License Number:
ISA License Number:
City Business Tax License Number:
Other
2
Indicate the total amount of work, expressed in dollars, which the applicant believes it is capable of undertaking
at any one time $
3
How many years has applicant been in business under present name?
As a Prime Contractor:
As a Subcontractor:
How many years experience in construction work has applicant had?
As a Prime Contractor:
As a Subcontractor:
4
IF AN OREGON CORPORATION, ANSWER THE FOLLOWING:
Date Incorporated:
(Check the box next to any officer who is authorized to execute contracts.)
President:
1
st
Vice President:
Secretary:
Treasurer:
City of Grants Pass
Contractor’s Prequalification Application
Page 8 of 17
Revised 02/2017
5
IF A CO-PARTNERSHIP, ANSWER THE FOLLOWING:
If a foreign co-partnership or persons engaging in business in this state under an assumed business name, but
not domiciled within this state, state whether or not such partnership or business organization has been
registered as may be required in compliance with Chapter 648, Oregon Revised Statutes.
Date of Organization:
State whether Partnership is: General
Limited
Association
Name of Partners:
Address of Partners:
6
IF A FOREIGN CORPORATION, ANSWER THE FOLLOWING:
Date Incorporated:
In What State:
Date of authorization
to transact business in
the State of Oregon:
Has Applicant filed the Department of Yes
Revenue forms required by ORS 279.021? No
(Check the box next to any officer who is authorized to execute contracts.)
President:
1
st
Vice President:
Secretary:
Name and Address of
Registered Agent in Oregon:
City of Grants Pass
Contractor’s Prequalification Application
Page 9 of 17
Revised 02/2017
7
Ownership and Control:
(a) List any organization, owned or controlled by the applicant, its officers, directors, partners and anyone
owning at least 10% interest in the firm, or in which the applicant was or is an officer, director or
partner, doing business in Oregon under another name.
(b) List those individuals, companies, or corporations owning 10% or more of the applicant’s firm.
(c) List all other personnel in applicant’s organization who have a financial interest in or serve as officers or
partners in another firm prequalified to bid in this or another state.
Individual’s Name
Position or Office
Other Firm(s)
Position in Other
Firm(s)
State of Other
Firm
8
Check the appropriate box or boxes identifying owners of the firm:
Woman Asian American Non Minority
Black
Hispanic
American Indian
A
laskan Native (Eskimo or Aleut)
Is your firm currently certified by the State of Oregon as a Disadvantaged Business Enterprise (DBE)?
Yes No
City of Grants Pass
Contractor’s Prequalification Application
Page 10 of 17
Revised 02/2017
9
Construction Experience of Individuals in the Organization:
What is the construction experience of all owners, officers, partners, and principal individuals in the applicant’s
organization? Also, list any other individual or organization who, in any way and to any extent, controls or
influences the bidding.
Individual’s Name
Position or
Office
Years of
Construction
Experience
Magnitude and Type of
Work
In What Capacity
City of Grants Pass
Contractor’s Prequalification Application
Page 11 of 17
Revised 02/2017
10
Bureau of Labor Training:
Is your firm an approved training agent under the Bureau of Labor and Industries’ Apprenticeship and
Training Division?
Yes No
11
Have you ever been denied prequalification in this or any other state? If yes, explain.
Have you ever been debarred from bidding on contracts in this or any other state under any State Law or
Federal Law? If yes, explain.
12
Trade Secret Statement:
Does the applicant want the material submitted herein deemed to be a trade secret pursuant to paragraphs
(b) and (e) of subsection (1) of ORS 192.500?
Yes No
13
General Remarks:
The following space may be used for general remarks and explanations pertaining to the foregoing
prequalification statements: (Also, explain any experience claimed which is that of a business organization
or entity, other than the applicant, including a business entity suspended by the applicant)
City of Grants Pass
Contractor’s Prequalification Application
Page 12 of 17
Revised 02/2017
14
Experience Questionnaire:
List major projects applicant has undertaken in last two years.
1
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
2
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
3
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
4
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
City of Grants Pass
Contractor’s Prequalification Application
Page 13 of 17
Revised 02/2017
14
(Continued)
Experience Questionnaire:
List major projects applicant has undertaken in last two years.
5
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
6
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
7
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
8
Project Name
Contract Amount
Class of Work
Date of Completion
Address/Location
Owner Name and Phone
Number
Surety Company If
Project Bonded
Indicate whether: Prime Contractor
Subcontractor
Joint Venture
City of Grants Pass
Contractor’s Prequalification Application
Page 14 of 17
Revised 02/2017
15
For Each Class of Work:
A. Enter the maximum dollar amount of work you are capable of performing.
B. Enter the maximum dollar amount of work you are qualified to undertake in other states.
C. Enter the state(s) qualified for the amount shown in column “B”.
D. Enter the number of years of experience in this class of work.
If more space is required, attach additional sheets.
(Highways, Roads, Streets, Airports)
CLASS
COLUMN A
MAX $ AMOUNT
COLUMN B
QUALIFIED $ AMOUNT
COLUMN C
STATE(S)
COLUMN D
YEARS
EXPERIENCE
Land Clearing – Highways, Roads,
Streets, and Airports
Earthwork and Drainage – Highways,
Roads, Streets, and Airport Runways
Aggregate Crushing
Aggregate Bases – Highways, Roads,
Streets, and Airport Runways
Asphalt Concrete Pavement and
Oiling – Highways, Roads, Streets,
and Airport Runways
Portland Cement Pavement –
Highways, Roads, Streets, and
Airport Runways
Reinforced Concrete, Structural Steel
Bridges, and Grade Separation
Structures
Painting Steel Bridges and Grade
Separation Structures
Miscellaneous Highway
Appurtenances (Guard Rails, Median
Barriers, Curbs, Retaining Walls,
Walks, Fences, Riprap)
Signing – Temporary and/or
Permanent for Highways, Streets,
and Roads
Illumination – Highways, Streets,
Roads, Airports, Parks, and Rest
Areas
Traffic Signals – Highways, Streets,
and Roads
Landscaping – Highways, Streets,
Roads, Parks, and Rest Areas
(Roadside Seeding, Lawns, Shrubs,
Trees, and Irrigation Systems)
Buildings – Highways, Rest Areas,
Parks (Toilets, Bathhouses,
Maintenance, Sand Sheds)
City of Grants Pass
Contractor’s Prequalification Application
Page 15 of 17
Revised 02/2017
15
(Continued)
A. Enter the maximum dollar amount of work you are capable of performing.
B. Enter the maximum dollar amount of work you are qualified to undertake in other states.
C. Enter the state(s) qualified for the amount shown in column “B”.
D. Enter the number of years of experience in this class of work.
If more space is required, attach additional sheets.
(Other Public Improvements)
CLASS
COLUMN A
MAX $ AMOUNT
COLUMN B
QUALIFIED $ AMOUNT
COLUMN C
STATE(S)
COLUMN D
YEARS
EXPERIENCE
Sewer Construction
Sewer Treatment Plants
Sewage Pumping Station
Water Lines
Water Reservoirs
Water Tanks – Steel, Concrete,
Wooden
Electrical Wiring
Building Construction
Building Alteration and Repair
Demolition and Related Excavation
and Clearing
Painting and Decorating
Plumbing
Heating
Air Conditioning
Roofing
Sheet Metal Work
Drainage
Well Drilling
Municipal Street Construction
Other
City of Grants Pass
Contractor’s Prequalification Application
Page 16 of 17
Revised 02/2017
16
Equipment Questionnaire:
Plants and equipment owned by the applicant: List only major items. Lump together small equipment and tools.
Quantity, Description, and Capacity of Items
Age in Years
Condition
Total Market Value of Equipment: $
Does applicant intend to rent equipment? If so, provide a general description?
Where available?
City of Grants Pass
Contractor’s Prequalification Application
Page 17 of 17
Revised 02/2017
17
AFFIDAVIT:
STATE OF OREGON )
) ss.
County of )
I, being first sworn, state that I am the
NAME
of the applicant herein and that the statements made
TITLE
in this application are true and I acknowledge that any false, deceptive or fraudulent statements on the
application or at a hearing will result in the denial of prequalification, that should there be any subsequent
material reduction in applicant’s ability to carry out any project for which applicant desires to submit a bid
applicant will give written notice of such change to the designated officer to whom this application is submitted
at least ten days prior to the bid opening; and that it is understood that such notice may change the eligibility of
applicant to submit the bid.
SIGNATURE
TITLE
Subscribed and sworn to before me this day of , 20
NOTARY PUBLIC
My Commission Expires:
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Form 868 Prequalification Application (City of Grants Pass)

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Completed 14 July 2020

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