City of Columbia



Community Development Block Grant (CDBG) Disaster Recovery Program

1225 Lady Street, Suite 102, Columbia, SC 29201

Contractor’s Application

To be considered for projects all Builders and Contractors must meet city, state and federal minimum requirements.

BUSINESS NAME: _______________________________________

Corporation

Limited Liability Corporation

Partnership

Sole Proprietor

BUSINESS ADDRESS: ____________________________________

____________________________________

BUSINESS TIN: ____________________________________

BUSINESS TELEPHONE: __________________________________

BUSINESS MOBILE: __________________________________

BUSINESS EMAIL ADDRESS: ______________________________

BUSINESS WEBSITE ADDRESS: ____________________________

Please indicate your company line of business:

New Construction

Remodeling

Lead Based Paint

Mold Remediation

Asbestos

Other:____________________________

Please List Certifications and/or Licenses

|Certifications |Licenses |

| | |

| | |

| | |

Business Name Search

The South Carolina Secretary of State’s records and the System for Award Management (SAM) database will be searched to determine if the company is registered, active and in good standing. In addition, bankruptcy records will be searched utilizing the last 4 digit of the business owner’s social security number.

1. In what year was your business started? If sole proprietor, indicated the year you started in the construction industry. __________________________

1. If applicable, provide any former name (s) your business has operated under and when? _____________________________________________________

2. Principle Owner (s) Name: _____________________________ Last 4 digit of Business Owner SS#: ______

_____________________________ Last 4 digit of Business Owner SS#: ______

Membership/Licensing

1. Is your company a member of the Home Builders Association or The Building Industry Association of Central South Carolina? YES or NO

If yes, name of association and member#:_____________________________________________________

2. List the jurisdiction and trade categories in which your organization is legally qualified to do business, and indicate the registration or license numbers, if applicable. __________________________________________

Experience & References

Submit the following information: name, address and a daytime phone number of three (3) clients who have benefitted from your companies home improvement services within the past twenty-four (24) months. All information requested must be completely provided and it will be fully verified.

These responses must indicate that their overall experience was favorable.

Provide contact information for (3) of your most recent completed projects.

|Owner/Project |Project Location |Contact Daytime Phone Number |

|MM/YY completed |Cost of Project | |

| | | |

| | | |

| | | |

Provide contact information for (3) projects currently under construction.

|Owner/Project |Property Location |Contact Daytime Phone Number |

|MM/YY work started |Cost of Project | |

| | | |

| | | |

| | | |

Provide references for at least (3) suppliers; (1) must be a major supplier

Accounts must have been open for a minimum of two years. At least one is required from a major supplier. Do not list subcontractors.

|Name |Account Number |Contact Phone #/ Email Address or Fax # |

| | | |

| | | |

| | | |

Attach copies of the following items:

1. Current City of Columbia Business License

2. Current Federal Lead Based Paint Certification requirements for persons performing Lead Based Paint Construction Activities and all other Certifications

3. LLR Residential Home Builder License OR LLR General Contractor License

4. Certificate of Insurance with a minimum General Liability of $300,000 (homeowner project only) or $2,000,000 (City owned projects and /or homeowner projects)

Acknowledgement and Agreement for Release of Information:

In order to evaluate the Residential Builder’s and General Contractor’s qualifications for placement on the City of Columbia’s Community Development Approval List, the undersigned hereby gives its/their consent to the City to contact business credit reporting agencies, named suppliers, project references, and to receive updates as may be required until such time this authorization shall be revoked, in writing. Should the 3rd party request verification to release information to the City of Columbia, we will provide a copy of this signature page for authorization.

I declare, certify, verify or state that, under penalty of perjury under the laws of the United States of America, the foregoing is true and correct. 

Company Name: _________________________________________________________

Printed Name: _________________________________________________________ Date: _____________

Signature: __________________________________________ Title: ________________________________

Please return completed application to:

Attention: Crystal Hatten

Columbia CDBG Disaster Recovery Program

1225 Lady Street, Suite 102, Columbia, SC 29201

cghatten@

Phone: (803) 545-4465

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