Qualification Statement 2-16-11 (Prolog)



Contractor’s Qualification StatementGeneral Description of Work:Please answer the following questions in the order listed. Include the questions with your response in the desired format in which you wish to present your information.The Undersigned certifies that the information provided herein is true and sufficiently complete so as not to be misleading.SUBMITTED TO:Brasfield & Gorrie, LLCCompany NameEmployer Identification NumberPrior Experience with B&G(if yes, provide year of last project)Street addressCity, State, Zip Code(street address only)Post Office BoxCity, State, Zip Code(post office box only)Phone NoFax NoContactEmail AddressCompany Web AddressSubmitted ByPrincipal OfficeTYPE OF WORK FORMCHECKBOX Subcontractor FORMCHECKBOX Vendor FORMCHECKBOX Manufacturer FORMCHECKBOX Consultant FORMCHECKBOX OtherTYPE OF COMPANY FORMCHECKBOX Corporation FORMCHECKBOX Partnership FORMCHECKBOX Individual FORMCHECKBOX Joint Venture FORMCHECKBOX OtherGENERAL INFORMATIONThere is no expressed or implied obligation for Brasfield & Gorrie to reimburse responding firms for any expenses incurred in preparing qualifications in response to this ANIZATIONHow many years has your organization been in business as a Subcontractor? How many years has your organization been in business under its present business name?Under what other or former names has your organization operated?SAFETY3.1Describe your safety program. Provide any information on any particular safety issues you would anticipate on this project and how your company would handle them.3.2Provide worker compensation experience modification rate for the past five (5) years:YearRateCarrier201620152014201320123.3Provide number of OSHA Citations for the past five (5) years: YearCitationsReasons20162015201420132012LICENSINGList jurisdictions and trade categories in which your organization is legally qualified to do business, and indicate registration or license numbers, if applicable. Please use the attached checklist to complete.Please check each of the following that applies to your organization: (List the Certify Agency and the Certification No.)4.2.1 FORMCHECKBOX Minority4.2.2 FORMCHECKBOX Woman Owned4.2.3 FORMCHECKBOX Disadvantaged4.2.4 FORMCHECKBOX Veteran4.2.5 FORMCHECKBOX Small Business4.2.6 FORMCHECKBOX Other (specify)EXPERIENCEList the categories of work that your organization normally self performs:Claims and Suits. (If the answer to any of the questions below is yes, please attach details.)Has your organization ever failed to complete any work awarded to it? Are there any judgments, claims, arbitration proceedings or suits pending or outstanding against your organization or its officers? Has your organization filed any lawsuits or requested arbitration with regard to construction contracts within the last five (5) years? Within the last five (5) years, has any officer or principal of your organization ever been an officer or principal of another organization when it failed to complete a construction contract? (If the answer is yes, please attach details.) List major construction projects your organization currently has in progress: project name:general contractor:contract amount:owner:general contractor contact:% complete:arch:general contractor phone:scheduled completion date:project name:general contractor:contract amount:owner:general contractor contact:% complete:arch:general contractor phone:scheduled completion date:project name:general contractor:contract amount:owner:general contractor contact:% complete:arch:general contractor phone:scheduled completion date:project name:general contractor:contract amount:owner:general contractor contact:% complete:arch:general contractor phone:scheduled completion date:project name:general contractor:contract amount:owner:general contractor contact:% complete:arch:general contractor phone:scheduled completion date:State total value of work under contract and work under contract remaining to be completed to date:List the major projects your organization has completed in the past five (5) years:project name:general contractor:job amount:owner:general contractor contact:date of completion:arch:general contractor phone:work performed:project name:general contractor:job amount:owner:general contractor contact:date of completion:arch:general contractor phone:work performed:project name:general contractor:job amount:owner:general contractor contact:date of completion:arch:general contractor phone:work performed:project name:general contractor:job amount:owner:general contractor contact:date of completion:arch:general contractor phone:work performed:project name:general contractor:job amount:owner:general contractor contact:date of completion:arch:general contractor phone:work performed:* Attach any additional projects.List your company’s annual volume for the past five (5) years:Year Volume2016 2015 2014 2013 2012 List your company’s largest contract to date:Job Name:Value: Date Completed:Please enter the project value range for the scope of work that your company is interested in pursuing.Project Size min $Project Size max $REFERENCESTrade References:firm:address:phone:contact:city, state, zip:firm:address:phone:contact:city, state, zip:firm:address:phone:contact:city, state, zip:Bank References:bank:address:phone:contact:city, state, zip:bank:address:phone:contact:city, state, zip:Please provide a current letter from the Surety Company and ask that the surety agent specifically certify any open performance bond claims and length of relationship.State the name and rating of your bonding company.surety company:address:phone:contact:city, state, zip:rating: State the name of your bonding agent and your bonding capacity.bonding agent:address:phone:contact:city, state, zip:total aggregate bonding capacity: single project bonding capacity: PLEASE FURNISH THE FOLLOWING ADDITIONAL INFORMATION:List total number of field employees that your company currently employs. List total number of office employees that your company currently employs. What percentage of work does your company perform with its own forces?SIGNATUREDated at this day of , 2016Name of Organization: By: Title: 10.2Mr./Ms. being duly sworn deposes and says that the information provided herein is true and sufficiently complete so as not to be misleading.Subscribed and sworn before me this day of , 2016Notary Public: My Commission Expires: Attachment A: CSI Codes (Page 1 Of 3)Please Mark All Scopes Of Work You Perform?011500Insurance & Bonding?061300Heavy Timber Fabricators & Ints.?013100GC's & Project Management?061753Wood Trusses?013200Reprographics & Plan Room?062000Finish Carpentry & Woodwork?013425Landscapre & Hardscape Design?064100Architectural Wood Casework?014523Material Testing?065000Plastic Fabrication?015416Material & Personnel Hoists?070000Thermal & Moisture Protection?015419Cranes?071000Waterproofing & Sealants?015423Scaffolding?072119Spray Foam Insulation?015430Equipment Rental?072126Blown Insulation?017423Final Cleaning?072400Exterior Insulation & Finish System?018500Safety Equipment?073100Shingle & Shake Roofing?019501Dump Truck Services?074100Metal Roofing?022100Professional Surveying?074200Metal & Composite Wall Panels?024100Demolition?074600Siding?028000Hazardous Material Remediation?075200Modified Bit Roofing?030500Turn Key Concrete Contractors?075400Mebrane Rfg. (TPO, PVS, EPDM)?032100Concrete Reinforcing Material Suppliers?077600Roof Paver Systems?032101Concrete Reinforcing Installers?078100Fireproofing?033000Concrete Material Suppliers?078400Fire Stopping?033500Concrete Finishers?079500Expansion Control?033716Concrete Pumping?081000Standard Doors, Frames, & Hdwr. ?033800Post Tensioned Material Suppliers?081001Door & Hardware Installation?034100Precast Structural Shapes?083100Access Doors?034500Precast Architectual Concrete?083463Detention Doors, Frames, & Hdwr. ?034713Concrete Tilt Wall?084300Storefront?034800Caststone Suppliers?084400Curtainwall?042000Masonry ?084500Translucent Panel Systems?051200Structural Steel?085000Prehung Windows?051201Steel Erection?086000Skylights?054400Light Gage Metal Trusses?088000Glass & Glazing?054500Unistrut?089100Louvers & Vents?055100Metal Stairs?092000Metal Studs & Drywall?055200Miscellaneous Steel?092001Drywall Material Suppliers?055213Pipe & Tube Railings?092400Gypsum Plaster?055900Metal Specialties (Balconies / Gratings)?092423Stucco?057314Ornamental Railings?092713GFCP & GFRC Fabrication?060140Wood Restoration & Refinishing?093100Ceramic, Porcelain, & Quarry Tile?060500Lumber Suppliers?095100Acoustical Ceilings?061053Rough Carpentry Subcontractors?095413Metal Ceilings?061100Wood Frame Contractors?095416Luminous CeilingsAttachment A: CSI Codes (Page 2 Of 3)Please Mark All Scopes Of Work You Perform?096201Polished Concrete Floors?111319Loading Dock Lifts?096300Stone Flooring?111400Pedestrian Control Equipment?096400Wood Flooring?111600Vaults and Safes?096500Resilient Flooring?112400Window Washing Equipment?096600Terrazzo Flooring?113100Residential Appliances?096713Elastomeric Liquid Flooring?114400Food Service Equipment?096723Resinous Flooring?115100Library Equipment?096766Fluid-Applied Athletic Flooring?115213Audio Visual Equipment?096800Carpeting?115300Laboratory Equipment?096900Access Flooring?116813Playground Equipment?097200Wall Coverings?116833Athletic Field Equipment?097500Stone Facing?117000Healthcare Equipment?097723Fabric Wrapped Panels?118213Solid Waste Bins?097800Wall Panels?122100Window Blinds?098400Acoustical Panels?123100Casework?099100Painting?123600Countertops?101100Visual Display Boards?124813Entrance Mats?101400Int. & Ext. Fabricated Signage?125100Office Furniture?101416Interior Room Signage?126100Fixed Audience Seating?102100Compartments (Toilet, Shower, etc)?129323Benches, Trash Recp., & Bicycle Rks.?102213Wire Mesh Partitions?133419Pre-Engineered Metal Buildings?102219Demountable Partitions?134900Radio and Radiation Protection?102233Operable Partitions?131100Swimming Pools?102500Service Walls?131200Fountains?102600Wall Protection?131300Aquariums?102800Toilet and Bath Specialties?132000Special Purpose Rooms?103200Fireplaces?141000Dumbwaiters?104400Fire Extinguishers?142000Elevators?105100Lockers?143000Escalators and Moving Walks?105500Postal Boxes?144000Wheel Chair Lifts?105613Shelving?149100Chutes?105626Motorized Mobile Strg. Shelving?149200Pneumatic Tube Systems?107113Exterior Sun Control Devices?210000Fire Suppression?107313Fabric Awnings?221000Plumbing?107316Metal Canopies & Walkway Covers?221005Plumbing Equip. & Material Supp.?107343Exterior Pre-Fabricated Shelters?236000HVAC Systems - 2, 3, & 4 ?111100Vehicle Service Equipment?237000HVAC Sys. - Pkg., DX, & Split Sys.?111200Parking Control Equipment?260000ElectricalAttachment A: CSI Codes (Page 3 Of 3)Please Mark All Scopes Of Work You Perform?260005Electrical Equip. & Material Suppliers?335100Natural Gas Distribution?264100Lightning Protection?337000Electrical Utility Distribution?264200Cathodic Protection?338000Communication Utility Distribution?265000Lighting Suppliers?341100Rail Track270000Communications / Low Voltage / Telecom344113Traffic Signals?271000Structured Cabling?347100Road Construction?274117Board & Conference Room AV Sys. ?347113Vehicular Guard Rails & Spec?281300Access Control Systems?400005Process Piping?281600Security Systems?480000Electrical Power Generation Division?282300Video Surveillance Systems?481400Solar Energy Electrical Pwr. Gen. Eq.?283000Fire Alarm Systems? ?312000Site Grading & Earthwork????312316Blasting????312319Dewatering????313100Soil Treatment????313400Soil Stabilization / Reinforcement????314100Shoring????315100Soil & Rock Anchors????315200Cofferdams????316200Driven Piles????316300Auger Cast Piles????316326Drilled Caissons / Piers????316613Rammed Aggregate Piers????321216Asphalt Paving????321313Concrete Paving????321413Concrete or Brick Pavers????321613Curb and Gutter????321623Sidewalks????321723Pavement Markings????323113Chainlink Fences????323400Fabricated Bridges????328000Irrigation????329000Landscaping and Planting????329200Grassing????331000Domestic Water & Fire Dist.????332000Wells????333000Sanitary Sewer????334000Storm Drainange????334500Storm Drainange Piping???Attachment B: State Licenses Please mark all states in which you are licensed.NATIONWIDEAlaska - AKAlabama - ALArkansas - ARArizona - AZCalifornia - CAColorado - COConnecticut - CTDistrict of Columbia - DCDelaware - DEFlorida - FLGeorgia - GAHawaii - HIIowa - IAIdaho - IDIllinois - ILIndiana - INKansas - KSKentucky - KYLouisiana - LAMassachusetts - MAMaryland - MDMaine - MEMichigan - MIMinnesota - MNMissouri - MOMississippi - MSMontana - MTNorth Carolina - NCNorth Dakota - NDNebraska - NENew Hampshire - NHNew Jersey - NJNew Mexico - NMNevada - NVNew York - NYOhio - OHOklahoma - OKOregon - ORPennsylvania - PARhode Island - RISouth Carolina - SCSouth Dakota - SDTennessee - TNTexas - TXUtah - UTVirginia - VAVermont - VTWashington - WAWisconsin - WIWest Virginia - WVWyoming - WY ................
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