Façade Structural Steel and Glass Package …philapark.org/wp-content/uploads/2013/12/PREQUAL-FORM-GC...For: 8 th & Filbert Streets Transformation Project General Construction; including

Philadelphia Parking Authority July 2013 8th & Filbert Sts Transformation Project Application For Prequalification For Construction Work

Prequalification Forms 1 of 51

PRE-QUALIFICATION FORMS For: 8th & Filbert Streets Transformation Project

General Construction; including Architectural, Civil, Structural Construction plus other Construction Operations

Façade Structural Steel and Glass Package

Mechanical/Plumbing Work: Electrical Work:

Hazardous Materials/Demolition: □ GENERAL CONSTRUCTION WORK

□ FAÇADE STRUCTURAL STEEL & GLASS PACKAGE □ HAZARDOUS MATERIALS/DEMOLITION WORK □ MECHANICAL/PLUMBING WORK □ ELECTRICAL WORK

Philadelphia Parking Authority July 2013 8th & Filbert Sts Transformation Project

Application For Prequalification □ General Construction □ Mechanical/Plumbing □ Electrical □ Hazardous Materials/Demolition □ Façade Structural Steel and Glass Package

Bidder: _____________________________________________________________________


Date Submitted:

_______________

Contractor Federal EIN No.:

________________________

City Business Tax ID No.:

__________________________

PA License No.: ___________

Exp. Date: ________________

Submitted by: Individual □ Corporation □ Partnership □

Principal Office Street Address (Address cannot be a PO Box):

Number: ____________

Street Address: _____________________________________

Suite No.: _____________________________________

City: _____________________________________

State: _____________________________________

Zip Code: _____________________________________

Principal Office Telephone No.: ____________

Principal Office Fax No.: ____________

Principal Office Email Address: ____________

_________________________________________

Principal Office Web Address: _____________

_________________________________________

Number of Full Time Employees: Check One Under 25 □ Under 50 □ Under 100 □ Over 100 □

CORPORATION PARTNERSHIP

Date of Incorporation:

______________

State:

_____

Capitalization:

_______________

Date of Organization:

___________________

Type: General □ Limited □

Other □

If other, state Partnership Type: ___

OFFICER PARTNERS



Bidder: _____________________________________________________________________


President:

Name: ___________________________________

Address: ____________________________________

____________________________________

Name: ____________________________________________

Address: ____________________________________________

____________________________________________

Vice President:

Name: ___________________________________

Address: ___________________________________

___________________________________

Name: ____________________________________________

Address: _____________________________________________

____________________________________________

Secretary:

Name: ___________________________________

Address: ___________________________________

___________________________________

Name: _____________________________________________

Address: _____________________________________________

_____________________________________________

Treasurer:

Name: : ___________________________________

Address: ___________________________________

___________________________________

Name:

Address: ___________________________________

___________________________________



Bidder: _____________________________________________________________________


EXPERIENCE AND EQUIPMENT 1a. Number of years your organization has been in business as a contractor under its present business name: ___ yrs

1b. List all other business names under which your organization has been in business as a construction contractor over the last 10 years:

1. _____________________________________ 2. ______________________________________

3. _____________________________________ 4. _______________________________________

5. _____________________________________ 6. _______________________________________



Bidder: _____________________________________________________________________


2.a Number of years of experience your organization has as a prime contractor in the type of construction work for which you are seeking Pre-Qualification: _____ yrs

2.b. Provide Name, Address and Contact Working Phone Number for at least six Project Owners for which you performed work as a prime contractor:

1. Project: _______________________

Owner Name: _________________ Address: ___________________________________________

Year Work was performed: ____ Contact Phone No.: __________________________________

2. Project: _______________________



3. Project: _______________________



4. Project: _______________________



5. Project: _______________________



6. Project: _______________________



3.a Number of years of experience your organization has as a sub-contractor in the type of construction work for which you are seeking Pre-Qualification: ____ yrs

3.b. Provide Name, Address and Contact Working Phone Number for at least six Projects for which you performed work as a sub- contractor:

1. Project: __________________________

Prime Contractor: _________________ Prime Contractor’s Address: __________________________

__________________________

__________________________

Year Work was performed: ____ Contact Phone No.: __________________________

2. Project: __________________________

Prime Contractor: _________________ Prime Contractor’s Address: ________________________



Bidder: _____________________________________________________________________


4. Dollar amount your organization has done each year during the last six years as:

1. a prime contractor: Year 1: $ ____________ Year 2: $ ____________ Year 3: $ ___________

Year 4: $ ____________ Year 5: $ ____________ Year 6: $ ___________

2. a sub-contractor: Year 1: $ ____________ Year 2: $ ____________ Year 3: $ ___________

Year 4: $ ____________ Year 5: $ ____________ Year 6: $ __________

5. Description of the construction experience of the principal officers and managers (including superintendents) of your organization:

1. Name: _________________________________ Position/Office: _______________________

Type of work in which individual has experience: ____________________________________

Years of construction experience: __________________ Size of project worked on: ______________

Names of organizations worked for: _________________ Position held: ________________________

_________________ Position held: ________________________

_________________ Position held: ________________________

_________________ Position held: _ _______________________

2. Name: _________________________________ Position/Office: ______________________

Type of work in which individua l has experience: ___________________________________

Years of construction experience: __________________ Size of project worked on: _____________

Names of organizations worked for: _________________ Position held: _______________________

_________________ Position held: _______________________

_________________ Position held: _______________________

_________________ Position held: _______________________

_________________ Position held: _______________________



Bidder: _____________________________________________________________________





Names of organizations worked for: _________________ Position held: ________________________

_________________ Position held: ________________________

_________________ Position held: ________________________

_________________ Position held: ________________________

_________________ Position held: ________________________




Names of organizations worked for: _________________ Position held: _________________________

_________________ Position held: _________________________

_________________ Position held: _________________________

_________________ Position held: _________________________

_________________ Position held: _________________________

5. Name: _________________________________ Position/Office: ________________

Type of work in which individual has experience: _________________

Years of construction experience: __________________ Size of project worked on: _________

Names of organizations worked for: _________________ Position held: __________________

_________________ Position held: __________________

_________________ Position held: ___________________

_________________ Position held: ___________________

_________________ Position held: ___________________



Bidder: _____________________________________________________________________




Bidder: _____________________________________________________________________


6a.1 Has your organization within the last five years performed work for the Philadelphia Parking Authority: YES □ NO □

Has any of your work not been finally accepted by the Philadelphia Parking Authority: YES □ NO □

If the answer to above question is yes, please state:

Contract number : __________________________

Project name: __________________________

Explanation of the circumstances surrounding the non-acceptance: ______________________________

____________________________________________________________________________________

____________________________________________________________________________________

Has any of your work with the Philadelphia Parking Authority been the subject of a Claim: YES □ NO □


Contract number : __________________________

Project name: __________________________

Explanation of the circumstances surrounding the Claim: ______________________________

____________________________________________________________________________________

____________________________________________________________________________________

Description of Final Resolution of the Claim: ______________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

6a.2 Has your organization within the last five years performed work for the City of Philadelphia: YES □ NO □

Has any of your work not been finally accepted by the City of Philadelphia: YES □ NO □


Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Has any of your work with the City of Philadelphia been the subject of a Claim: YES □ NO □


Contract number : __________________________

Project name: __________________________

Explanation of the circumstances surrounding the Claim: ______________________________

____________________________________________________________________________________

____________________________________________________________________________________



Bidder: _____________________________________________________________________


6b.2 Has any officer, partner or other person active in the management of your organization, within the last five years, been an Officer, partner, manager, or sole proprietor of another organization which performed work for the City of Philadelphia: YES □ NO □

Has any of that work not been finally accepted by the City of Philadelphia: YES □ NO □


Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

6b.3 Has any officer, partner or other person active in the management of your organization, within the last five years, been an Officer, partner, manager, or sole proprietor of another organization which performed work for the Commonwealth of Pennsylvania: YES □ NO □

Has any of that work not been finally accepted by the Commonwealth of Pennsylvania: YES □ NO □


Contract number : __________________________

Project name: __________________________

Explanation of the circumstances surrounding the non-acceptance:



Bidder: _____________________________________________________________________


7b. Has the City of Philadelphia, within the past five years, declared your organization in default of a City of Philadelphia contract or otherwise terminated the contract? YES □ NO □


Contract number : __________________________

Project name: __________________________

Explanation of the circumstances surrounding the default: ______________________________

____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

7c. Has the Commonwealth of Pennsylvania, within the past five years, declared your organization in default of a Commonwealth of Pennsylvania contract or otherwise terminated the contract? YES □ NO □


Contract number : __________________________

Project name: __________________________



Bidder: _____________________________________________________________________



____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number : __________________________

Project name: __________________________


____________________________________________________________________________________

____________________________________________________________________________________

8a.1 Has a commercial surety for your organization, within the past five years, been called upon to complete any work on a contract with the Philadelphia Parking Authority? YES □ NO □


Contract number for which the surety was called upon to complete the work: ______________________

Project name for the Contract which the surety was called upon to complete the work: _______________



Bidder: _____________________________________________________________________


____________________________________________________________________________________

Explanation of the circumstances surrounding the event: ______________________________

____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________

8a.2 Has a commercial surety for your organization, within the past five years, been called upon to complete any work on a contract with the City of Philadelphia? YES □ NO □


Contract number for which the surety was called upon to complete the work: __________________


____________________________________________________________________________________




Bidder: _____________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________

Contract number for which the surety was called upon to complete the work: ___________________


____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________

8a.3 Has a commercial surety for your organization, within the past five years, been called upon to complete any work on a contract with the Commonwealth of Pennsylvania? YES □ NO □




____________________________________________________________________________________


____________________________________________________________________________________



Bidder: _____________________________________________________________________


____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________



____________________________________________________________________________________


____________________________________________________________________________________

____________________________________________________________________________________

8b1. Has any officer, partner or other person active in the management of your organization, within the last five years, been an officer, partner, manager, or sole proprietor of another organization whose commercial surety was called upon to complete any work on a contract with the Philadelphia Parking Authority? YES □ NO □

If Yes, state: Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________

______________________________________

______________________________________

Contract Number for which the surety was called upon to complete: ___________________



Bidder: _____________________________________________________________________


Project Name for the contract the surety was called upon to complete: _______________________________

Explanation of the circumstances: ___________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________

______________________________________

______________________________________

Contract Number for which the surety was called upon to complete: ___________________ Project Name for the contract the surety was called upon to complete: _______________________________


_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________ Contract Number for which the surety was called upon to complete: ___________________ Project Name for the contract the surety was called upon to complete: _______________________________


_______________________________________________________________________________________

_______________________________________________________________________________________



Bidder: _____________________________________________________________________


8b.2 Has any officer, partner or other person active in the management of your organization, within the last five years, been an officer, partner, manager, or sole proprietor of another organization whose commercial surety was called upon to complete any work on a contract with the City of Philadelphia? YES □ NO □


______________________________________

______________________________________

Contract Number for which the surety was called upon to complete: ___________________ Project Name for the contract the surety was called upon to complete: _______________________________ Explanation of the circumstances: ___________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________



Bidder: _____________________________________________________________________


______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________



Bidder: _____________________________________________________________________


8b.3 Has any officer, partner or other person active in the management of your organization, within the last five years, been an officer, partner, manager, or sole proprietor of another organization whose commercial surety was called upon to complete any work on a contract with the Commonwealth of Pennsylvania? YES □ NO □


______________________________________

______________________________________

Contract Number for which the surety was called upon to complete the work: ___________________ Project Name for the contract the surety was called upon to complete the work: _______________________


_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________

Name of individual: _________________________________________ Name of organization: ________________________________________



Bidder: _____________________________________________________________________


Address of organization: ______________________________________

______________________________________

______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________


______________________________________

______________________________________




Bidder: _____________________________________________________________________



_______________________________________________________________________________________

_______________________________________________________________________________________



Bidder: _____________________________________________________________________


9. Has any officer, partner, or other person active in the management of your organization, within the past five years, been an officer, partner, manager, or sole proprietor of another organization that was declared in default of a Philadelphia Parking Authority, a City of Philadelphia or a Commonwealth of Pennsylvania contract or otherwise terminated, or that failed to complete a Philadelphia Parking Authority, City of Philadelphia or Commonwealth of Pennsylvania contract? YES □ NO □

If Yes, state: Name of individual: _________________________________ Name of organization: ________________________________ Address of organization: _______________________________

_______________________________

_______________________________ Contract Number of contract defaulted or terminated: _________ Project Name for the contract defaulted or terminated: _______________________________________________

Explanation of the circumstances surrounding declaration of default or termination: ________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Name of individual: _________________________________ Name of organization: ________________________________ Address of organization: _______________________________

_______________________________

_______________________________ Contract Number of contract defaulted or terminated: _________ Project Name for the contract defaulted or terminated: _______________________________________________

Explanation of the circumstances surrounding declaration of default or termination: ________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Name of individual: _________________________________ Name of organization: ________________________________ Address of organization: _______________________________

_______________________________

_______________________________ Contract Number of contract defaulted or terminated: _________ Project Name for the contract defaulted or terminated:



Bidder: _____________________________________________________________________


10. Has your organization ever failed to complete any work under, or been declared in default of, a contract awarded to it by a public or private owner other than the City of Philadelphia, the Commonwealth of Pennsylvania or the Philadelphia Parking Authority? YES □ NO □

If Yes, state: Name of the Project Owner: ______________________________________________ Bid/Contract numbers (if applicable) for the project: ___________________________ Did the owner declare your organization in default of its contract? _________________ Description of the project: __________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________ Type of work your organization was providing: _________________________________________________ Date the work was started: ____________________ Date the work stopped: _________________ Reason the work was not completed: __________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Name of the Project Owner: ______________________________________________ Bid/Contract numbers (if applicable) for the project: ___________________________ Did the owner declare your organization in default of its contract? _________________ Description of the project: __________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________



Bidder: _____________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________



Bidder: _____________________________________________________________________



________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________



Bidder: _____________________________________________________________________


11. Has any officer, partner or other person active in the management of your organization ever been an officer, partner, manager or sole proprietor of another organization that failed to complete any work under, or been declared in default of, a contract awarded to it by a public or private owner other than the City of Philadelphia, the Commonwealth of Pennsylvania or the Philadelphia Parking Authority? YES □ NO □

If Yes, state: Name of the individual: _____________________________________ Name of the Project Owner: _________________________________ Bid/Contract numbers (if applicable) for the project: ______________ Did the owner declare the organization in default of its contract? YES □ NO □ Description of the project: __________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Type of work the individual was providing: ___________________________________________________ Date the work started: ____________________ Date the work stopped: _________________ Reason the work was not completed: _________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Name of the individual: _____________________________________ Name of the Project Owner: _________________________________ Bid/Contract numbers (if applicable) for the project: ______________ Did the owner declare the organization in default of its contract? YES □ NO □ Description of the project: __________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Type of work the individual was providing: ___________________________________________________ Date the work started: ____________________ Date the work stopped: _________________



Bidder: _____________________________________________________________________


Reason the work was not completed: _________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

Type of work the individual was providing: ___________________________________________________



Bidder: _____________________________________________________________________


Date the work started: ____________________ Date the work stopped: _________________ Reason the work was not completed: _________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


________________________________________________________________________________________



Bidder: _____________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________



Bidder: _____________________________________________________________________


12. Has any officer, partner or other person active in the management of your organization within the last five years, been Disqualified, Suspended, or Debarred (under its present name or any other name) from bidding on public contracts, or removed from a bidding list, by any state, federal agency or by the City of Philadelphia? YES □ NO □

If Yes, state: Name of agency that took such action: ________________________________________________________

Date(s) of the action: _____________

Type of work to which the contract(s) applied: ___________________________________________________

Reasons stated by the agency for the action: _____________________________________________________

Name of agency that took such action: ________________________________________________________

























Bidder: _____________________________________________________________________


13. Has any commercial surety ever refused to furnish a performance or payment bond for your organization? YES □ NO □

If Yes, state: Name of Surety that took such action: ________________________________________________________

Address of Surety: ____________________________________________

____________________________________________

____________________________________________

Type of contract for which bond was refused: _______________________

Project Owner’s name: _________________________________________

Type of work: _________________________ Date of contract: ___________________________

Reason stated by the surety for the refusal: _______________________________________________________

Name of Surety that took such action: _________________________________________________________


____________________________________________

____________________________________________







____________________________________________

____________________________________________







____________________________________________

____________________________________________




Bidder: _____________________________________________________________________


14. Has your organization or any officer, partner, or other person active in the management for your organization, or any shareholder holding an equity interest of more than five percent:

a. ever been convicted of or pleaded guilty or nolo contender to federal or state misdemeanor or felony charges (including but not limited to public bidding law or the making of false statements)? YES □ NO □

b. ever been refused coverage under any fidelity bond? YES □ NO □

15. Is your organization or any officer, partner, or other person active in the management of your organization, or any shareholder holding as equity interest of more than five percent:

a. currently under indictment on federal or state misdemeanor or felony charges? YES □ NO □

b. currently the subject of a state or federal grand jury investigation or under notification by local, state or federal law enforcement authorities that they are the subject of any criminal investigation? YES □ NO □

16. Has any officer, partner, director, shareholder, or other person active in the management of your organization been employed by the Philadelphia Parking Authority, the City of Philadelphia, the Commonwealth of Pennsylvania, or been appointed to a Political or other office of the City or State? YES □ NO □

If Yes, state: Name of individual: ______________________________________________________________________

Position held with the Philadelphia Parking Authority, the City or the Commonwealth of Pennsylvania; _____

________________________________________________________________________________________

Dates the employment or appointment began: _________________

Dates the employment or appointment ended: _________________

Name of individual: ______________________________________________________________________


________________________________________________________________________________________





________________________________________________________________________________________





________________________________________________________________________________________



Bidder: _____________________________________________________________________


17. Identify by name and business address, all organizations that are affiliated or subsidiaries of your organization. (Attach separate sheet of paper as needed)

Name of affiliate or subsidiary: _____________________________________________________________

Relationship to organization: ________________________________________________________________

Business address of affiliate or subsidiary: _____________________________________

_____________________________________

_____________________________________




_____________________________________

_____________________________________




_____________________________________

_____________________________________




_____________________________________

_____________________________________




_____________________________________

_____________________________________




_____________________________________

_____________________________________



Bidder: _____________________________________________________________________


18. Identify by name and business address, any organization or any individual (other than officers, partners and managers of your organization) that control or influence bidding by your organization. (Attach separate piece of paper if needed).

Name of organization/individual: _____________________________________________

Business address of organization/individual: ______________________________________

_______________________________________

_______________________________________

Name of organization/individual: ______________________________________________

Business address of organization/individual: _______________________________________

_______________________________________

_______________________________________

Name of organization/individual: _______________________________________________

Business address of organization/individual: ________________________________________

_____________________________________

______________________________________



_______________________________________

_______________________________________



_______________________________________

_______________________________________



_______________________________________

_______________________________________





Bidder: _____________________________________________________________________


_______________________________________

_______________________________________



_______________________________________

_______________________________________



_______________________________________

_______________________________________

19. Identify by name and business address, all organizations and all individuals that hold a financial interest in your organization of ten percent or more. (Attach separate piece of paper if needed).

Name of organization/individual : _____________________________________________

Business address of organization/individual: _____________________________________

_____________________________________

_____________________________________

Name of organization/individual : ________________________________________________


______________________________________

______________________________________



_____________________________________

_____________________________________

Name of organization/individual : ________________________________________________


______________________________________

______________________________________



Bidder: _____________________________________________________________________




_____________________________________

_____________________________________

20. Is your organization or any of its parent or subsidiary organizations currently indebted to the City of Philadelphia for any delinquent City taxes, taxes collected by the City on behalf of the School District of Philadelphia, liens, judgments, fees or other debts? YES □ NO □

If Yes, describe on a separate sheet of paper, the nature of debt, the amount of debt, lien, judgment or fee; the dates of any notices from the City and any written agreement or payment plan with the City for its disposition.

21.a If your organization has had construction contracts with the Philadelphia Parking Authority, list all such completed contracts within the last five years: (Duplicate page as needed)

Contract No.: _________________ Bid No.: ____________________ Amount of contract: ______________________

Project Description: _______________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Contract No.: _________________ Bid No.: ____________________ Amount of contract: _____________________

Project Description: _____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________


________________________________________________________________________________________________

_________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________





Bidder: _____________________________________________________________________


________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



_______________________________________________________________________________________________

_______________________________________________________________________________________________

21.b If your organization has had construction contracts with the City of Philadelphia, list all such completed contracts within the last five years: (Duplicate page as needed)


Project Description: ________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________

21.c If your organization has had construction contracts with the Commonwealth of Pennsylvania, list all such completed contracts



Bidder: _____________________________________________________________________


within the last five years: (Duplicate page as needed)



________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

__ ______________________________________________________________________________________________

Contract No.: _________________ Bid No.: ____________________ Amount of contract: ________________________


________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



________________________________________________________________________________________________

________________________________________________________________________________________________



Bidder: _____________________________________________________________________


22. List all incomplete contracts held by your organization at present: (Duplicate page as needed)

Contract No.: _________________ ___ % complete Amount of contract: ________________

Contracting Agency: _____________________________ Location of Project: ________________













23a. Have any liquidated damages or penalties been imposed by the Philadelphia Parking Authority on your organization? (Duplicate page as needed) YES □ NO □

If Answer is yes, please state: Name of agency that took such action: __________________________________________


Type of work to which the liquidated damages were applied: __________________________

Reasons stated by the agency for the action: _______________________________________

____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________ Contract No.: _________________ Amount of contract: ____________________



Bidder: _____________________________________________________________________


Name of agency that took such action: __________________________________________




____________________________________________________________________________

____________________________________________________________________________






____________________________________________________________________________

____________________________________________________________________________






____________________________________________________________________________

____________________________________________________________________________






Bidder: _____________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________


23b. Have any liquidated damages or penalties been imposed by the City of Philadelphia on your organization? (Duplicate page as needed) YES □ NO □





____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________

Contract No.: _________________ Amount of contract: ____________________





____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________







Bidder: _____________________________________________________________________



____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________






____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________






____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________


23.c Have any liquidated damages or penalties been imposed by the Commonwealth of Pennsylvania on your organization? (Duplicate page as needed) YES □ NO □







Bidder: _____________________________________________________________________


____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________






____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________






____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________






____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________



Bidder: _____________________________________________________________________







____________________________________________________________________________

____________________________________________________________________________

Project name: _______________________________________


23.d Have any liens, claims or stop notices been filed against your organization? YES □ NO □

If your answer is Yes to either question, state: Name of Claimant: ___________________________________________

Grounds asserted by Claimant: __________________________________

Disposition of the matter: _______________________________________

____________________________________________________________

Name of Claimant: __________________________________________


Disposition of the matter: ______________________________________

____________________________________________________________

Name of Claimant: __________________________________________



____________________________________________________________

Name of Claimant: __________________________________________



____________________________________________________________



Bidder: _____________________________________________________________________


Name of Claimant: __________________________________________



____________________________________________________________

Name of Claimant: __________________________________________

Grounds asserted by Claimant: __________________________________ Disposition of the matter: ______________________________________

____________________________________________________________

Name of Claimant: __________________________________________

Grounds asserted by Claimant: __________________________________ Disposition of the matter: ______________________________________

____________________________________________________________



Bidder: _____________________________________________________________________


24. Has your organization submitted, for any reason, a request to withdraw from a public bid after the bids were open, over the last five years? YES □ NO □

If your answer is Yes, state: Bid Number: __________________ Project Owner: ____________________________

Disposition of matter: ___________________________________________________________

_____________________________________________________________________________

__________________________________________________________________________

Bid Number: __________________ Project Owner: ___________________________

Disposition of matter: ________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

Bid Number: __________________ Project Owner: __________________________


_____________________________________________________________________________

__________________________________________________________________________



_____________________________________________________________________________

______________________________________________________________________________



_____________________________________________________________________________

__________________________________________________________________________



_____________________________________________________________________________

______________________________________________________________________________



Bidder: _____________________________________________________________________


25. List the largest project that your organization has completed over the last five years. (Duplicate page as needed)

Contract Number: _______________________ Amount of contract: ____________________________________

Contracting Agency: _______________________ Location of project: ____________________________________

Reference 1: Name: _______________________ Telephone Number: ____________________________________


Reference 3: Name: ________________________ Telephone Number: ___________________________________























Bidder: _____________________________________________________________________


26. List any projects that your organization has completed that are similar in nature to the project for which you’re applying for prequalification. (Duplicate page as needed)

Contract Number: _______________ Amount of contract: __________________ Date of contract: _______________

Contracting Agency: _______________________________ Location of project: ______________________________

Reference 1: Name: ________________________________ Telephone Number: _____________________________

Reference 2: Name: ______________________________ Telephone Number: _____________________________

Reference 3: Name: _______________________________ Telephone Number: _____________________________




















Reference 3: Name: _______________________________ Telephone Number: ____________________________



Bidder: _____________________________________________________________________


27. List any equipment owned by your organization that is available for the proposed work: (Duplicate page as needed)

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Bidder: _____________________________________________________________________


28a. In order for applications for prequalification to be considered by the Philadelphia Parking Authority, the organization’s current Safety Records and Ratings must be disclosed for: a. Commercial General Liability: ___________

b. Worker’s compensation: ___________

28b. PPA’s Insurance and Indemnifications Requirements for this Project are specified in Insert A, titled Insurance and Indemnification Requirements and herin enclosed.

28c. In order for applications for prequalification to be considered by the Philadelphia Parking Authority, a statement titled “CERTIFICATE OF LIABILITY INSURANCE AND INDEMNIFICATION” must be submitted along with the completed and fully executed Application Forms. The statement must certify that the insurance coverage of the applicant enterprise/organization meets or exceeds the requirements stated in Insert A. The statement also must certify that the applicant enterprise/organization is able to meet the Indemnification Requirements stated in Insert A, titled Insurance and Indemnification Requirements..

28c. The statement must be issued by the Applicant’s Insurance Carrier and signed both by the Applicant’s Insurance Carrier and an authorized representative of the Applicant organization.

28d. In order to be considered valid, the statement must be duly notarized.

29. Audited Financial Statements examined and prepared by an Independent Certified Public Accountant who is not an employee of the Applicant organization must be submitted along with the completed and fully executed Application Forms.

29a. In order to be considered in compliance with PPA’s prequalification requirements, Financial Statements must include the Independent Auditor’s Report, Statement of Net Assets, Statement of Revenue, Expenses and Changes in Fund Net Assets for the Current year and the Prior year, as well as Statement of Cash Flows and the accompanying Notes to the Financial Statements.

29b. Organizations applying for PreQualification must provide:

1. Total dollar amount of all available lines of credit at their organization’s disposal: $ _________________________

2. Total dollar amount of the balance of all available lines of credit at the organization’s disposal: $ ______________

NOTE: If prequalified for this bid, all bidders will be required to provide with their bid proposal, in addition to requirements set forth in the bid documents, documentation evidencing a dedicated line of credit or comparable type of available funds in an amount of no less than Five Hundred Thousand Dollars ($500,000.00). Toward satisfaction of the above requirement, the Authority will consider currently established credit with suppliers pertinent to performance of the job, provided that such existing credit does not exceed twenty percent (20%) of the total above requirement.



Bidder: _____________________________________________________________________


I/We hereby certify that the statements of fact contained herein are correct to the best of my/our knowledge and belief; and that the statement entitled “FINANCIAL POSITION” presents fairly the financial position of the organization and that the statement titled “CERTIFICATE OF LIABILITY INSURANCE AND INDEMNIFICATION” certifies that the insurance coverage of the enterprise/organization meets or exceeds the requirements stated above and that the enterprise/organization will meet all the Indemnification Requirements as specified in Insert A, hereby attached.

I/We acknowledge that if we make any false statements herein, I am / we are subject to such penalties as may be prescribed by law or ordinance.

Any depository, vendor, references, or other agency named herein is authorized to supply the holder with any information necessary to verify statement.

NOTE: A partnership must give firm name and signatures of all partners. A corporation must give full corporate name, signatures of two (2) officials (either President or Vice-President and Secretary or Treasurer) and affix corporate seal. _______________________ _______________________ ____________________ Date of Signing

Firm or Corporate Name Signature ____________________ Title _________________ Signature ____________________ Title _________________ Signature ____________________ Title _________________ Signature ______________________ Title _________________

Documents

Façade Structural Steel and Glass Package …philapark.org/wp-content/uploads/2013/12/PREQUAL-FORM-GC...For: 8 th & Filbert Streets Transformation Project General Construction; including