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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: _____________________________________________________________________
Prequalification Forms 2 of 51
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
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: _____________________________________________________________________
Prequalification Forms 3 of 51
President:
Name: ___________________________________
Address: ____________________________________
____________________________________
Name: ____________________________________________
Address: ____________________________________________
____________________________________________
Vice President:
Name: ___________________________________
Address: ___________________________________
___________________________________
Name: ____________________________________________
Address: _____________________________________________
____________________________________________
Secretary:
Name: ___________________________________
Address: ___________________________________
___________________________________
Name: _____________________________________________
Address: _____________________________________________
_____________________________________________
Treasurer:
Name: : ___________________________________
Address: ___________________________________
___________________________________
Name:
Address: ___________________________________
___________________________________
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: _____________________________________________________________________
Prequalification Forms 4 of 51
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. _______________________________________
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: _____________________________________________________________________
Prequalification Forms 5 of 51
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: _______________________
Owner Name: _________________ Address: ___________________________________________
Year Work was performed: ____ Contact Phone No.: __________________________________
3. Project: _______________________
Owner Name: _________________ Address: ___________________________________________
Year Work was performed: ____ Contact Phone No.: __________________________________
4. Project: _______________________
Owner Name: _________________ Address: ___________________________________________
Year Work was performed: ____ Contact Phone No.: __________________________________
5. Project: _______________________
Owner Name: _________________ Address: ___________________________________________
Year Work was performed: ____ Contact Phone No.: __________________________________
6. Project: _______________________
Owner Name: _________________ Address: ___________________________________________
Year Work was performed: ____ Contact Phone No.: __________________________________
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: ________________________
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: _____________________________________________________________________
Prequalification Forms 6 of 51
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: _______________________
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: _____________________________________________________________________
Prequalification Forms 7 of 51
3. 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: ________________________
4. 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: _________________________
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: ___________________
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: _____________________________________________________________________
Prequalification Forms 8 of 51
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: _____________________________________________________________________
Prequalification Forms 9 of 51
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 □
If the answer to above question is yes, please state:
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 □
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 City of Philadelphia been the subject of a Claim: YES □ NO □
If the answer to above question is yes, please state:
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the Claim: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 10 of 51
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 □
If the answer to above question is yes, please state:
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the non-acceptance: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the non-acceptance: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the non-acceptance: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the non-acceptance: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 □
If the answer to above question is yes, please state:
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the non-acceptance:
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: _____________________________________________________________________
Prequalification Forms 11 of 51
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 □
If the answer to above question is yes, please state:
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 □
If the answer to above question is yes, please state:
Contract number : __________________________
Project name: __________________________
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: _____________________________________________________________________
Prequalification Forms 12 of 51
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contract number : __________________________
Project name: __________________________
Explanation of the circumstances surrounding the default: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 □
If the answer to above question is yes, please state:
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: _______________
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: _____________________________________________________________________
Prequalification Forms 13 of 51
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
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 □
If the answer to above question is yes, please state:
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
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: _____________________________________________________________________
Prequalification Forms 14 of 51
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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 □
If the answer to above question is yes, please state:
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 15 of 51
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: _______________
____________________________________________________________________________________
Explanation of the circumstances surrounding the event: ______________________________
____________________________________________________________________________________
____________________________________________________________________________________
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: ___________________
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: _____________________________________________________________________
Prequalification Forms 16 of 51
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: _______________________________
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: _______________________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 17 of 51
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 □
If Yes, state: 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: _______________________________ 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: _______________________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________
______________________________________
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: _____________________________________________________________________
Prequalification Forms 18 of 51
______________________________________
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: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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: _______________________________
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: _______________________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 19 of 51
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 □
If Yes, state: Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________
______________________________________
______________________________________
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: _______________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________
______________________________________
______________________________________
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: _______________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Name of individual: _________________________________________ Name of organization: ________________________________________
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: _____________________________________________________________________
Prequalification Forms 20 of 51
Address of organization: ______________________________________
______________________________________
______________________________________
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: _______________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________
______________________________________
______________________________________
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: _______________________
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Name of individual: _________________________________________ Name of organization: ________________________________________ Address of organization: ______________________________________
______________________________________
______________________________________
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: _______________________
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: _____________________________________________________________________
Prequalification Forms 21 of 51
Explanation of the circumstances: ___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 22 of 51
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:
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: _____________________________________________________________________
Prequalification Forms 23 of 51
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: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________ Type of work your organization was providing: _________________________________________________ Date the work was started: ____________________ Date the work stopped: _________________ Reason the work was not completed: __________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 24 of 51
________________________________________________________________________________________
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: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________ Type of work your organization was providing: _________________________________________________ Date the work was started: ____________________ Date the work stopped: _________________ Reason the work was not completed: __________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 25 of 51
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: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________ Type of work your organization was providing: _________________________________________________ Date the work was started: ____________________ Date the work stopped: _________________ Reason the work was not completed: __________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 26 of 51
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: _________________
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: _____________________________________________________________________
Prequalification Forms 27 of 51
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: _________________ 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: ___________________________________________________
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: _____________________________________________________________________
Prequalification Forms 28 of 51
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: _________________ 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: __________________________________________________________________
________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 29 of 51
________________________________________________________________________________________
Type of work the individual was providing: ___________________________________________________ Date the work started: ____________________ Date the work stopped: _________________ Reason the work was not completed: _________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 30 of 51
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: ________________________________________________________
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: ________________________________________________________
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: ________________________________________________________
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: ________________________________________________________
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: ________________________________________________________
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: ________________________________________________________
Date(s) of the action: _____________
Type of work to which the contract(s) applied: ___________________________________________________
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: _____________________________________________________________________
Prequalification Forms 31 of 51
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: _________________________________________________________
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: _________________________________________________________
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: _________________________________________________________
Address of Surety: ____________________________________________
____________________________________________
____________________________________________
Type of contract for which bond was refused: _______________________
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: _____________________________________________________________________
Prequalification Forms 32 of 51
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: ______________________________________________________________________
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: ______________________________________________________________________
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: ______________________________________________________________________
Position held with the Philadelphia Parking Authority, the City or the Commonwealth of Pennsylvania; _____
________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 33 of 51
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: _____________________________________
_____________________________________
_____________________________________
Name of affiliate or subsidiary: _____________________________________________________________
Relationship to organization: ________________________________________________________________
Business address of affiliate or subsidiary: _____________________________________
_____________________________________
_____________________________________
Name of affiliate or subsidiary: _____________________________________________________________
Relationship to organization: ________________________________________________________________
Business address of affiliate or subsidiary: _____________________________________
_____________________________________
_____________________________________
Name of affiliate or subsidiary: _____________________________________________________________
Relationship to organization: ________________________________________________________________
Business address of affiliate or subsidiary: _____________________________________
_____________________________________
_____________________________________
Name of affiliate or subsidiary: _____________________________________________________________
Relationship to organization: ________________________________________________________________
Business address of affiliate or subsidiary: _____________________________________
_____________________________________
_____________________________________
Name of affiliate or subsidiary: _____________________________________________________________
Relationship to organization: ________________________________________________________________
Business address of affiliate or subsidiary: _____________________________________
_____________________________________
_____________________________________
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: _____________________________________________________________________
Prequalification Forms 34 of 51
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: ________________________________________
_____________________________________
______________________________________
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: ______________________________________
_______________________________________
_______________________________________
Name of organization/individual: ______________________________________________
Business address of organization/individual: _______________________________________
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: _____________________________________________________________________
Prequalification Forms 35 of 51
_______________________________________
_______________________________________
Name of organization/individual: _____________________________________________
Business address of organization/individual: ______________________________________
_______________________________________
_______________________________________
Name of organization/individual: ______________________________________________
Business address of organization/individual: _______________________________________
_______________________________________
_______________________________________
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 : ________________________________________________
Business address of organization/individual: _______________________________________
______________________________________
______________________________________
Name of organization/individual : _____________________________________________
Business address of organization/individual: _____________________________________
_____________________________________
_____________________________________
Name of organization/individual : ________________________________________________
Business address of organization/individual: _______________________________________
______________________________________
______________________________________
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: _____________________________________________________________________
Prequalification Forms 36 of 51
Name of organization/individual : _____________________________________________
Business address of organization/individual: _____________________________________
_____________________________________
_____________________________________
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: _______________________
Project Description: _______________________________________________________________________________________________
________________________________________________________________________________________________
_________________________________________________________________________________________________
Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________
Project Description: _______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________
Project Description: _______________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 37 of 51
________________________________________________________________________________________________
________________________________________________________________________________________________
Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________
Project Description: _______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________
Project Description: _______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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)
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: _______________________
Project Description: ________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________
Project Description: _______________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
21.c If your organization has had construction contracts with the Commonwealth of Pennsylvania, list all such completed contracts
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: _____________________________________________________________________
Prequalification Forms 38 of 51
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: _______________________
Project Description: _______________________________________________________________________________________________
________________________________________________________________________________________________
__ ______________________________________________________________________________________________
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: ________________________
Project Description: ________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Contract No.: _________________ Bid No.: ____________________ Amount of contract: _______________________
Project Description: ________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 39 of 51
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: ________________
Contract No.: _________________ ___ % complete Amount of contract: ________________
Contracting Agency: _____________________________ Location of Project: ________________
Contract No.: _________________ ___ % complete Amount of contract: ________________
Contracting Agency: _____________________________ Location of Project: ________________
Contract No.: _________________ ___ % complete Amount of contract: ________________
Contracting Agency: _____________________________ Location of Project: ________________
Contract No.: _________________ ___ % complete Amount of contract: ________________
Contracting Agency: _____________________________ Location of Project: ________________
Contract No.: _________________ ___ % complete Amount of contract: ________________
Contracting Agency: _____________________________ Location of Project: ________________
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: __________________________________________
Date(s) of the 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: ____________________
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: _____________________________________________________________________
Prequalification Forms 40 of 51
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the action: _____________
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: _____________________________________________________________________
Prequalification Forms 41 of 51
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: ____________________
23b. Have any liquidated damages or penalties been imposed by the City of Philadelphia on your organization? (Duplicate page as needed) YES □ NO □
If Answer is yes, please state: Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the action: _____________
Type of work to which the liquidated damages were applied: __________________________
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: _____________________________________________________________________
Prequalification Forms 42 of 51
Reasons stated by the agency for the action: _______________________________________
____________________________________________________________________________
____________________________________________________________________________
Project name: _______________________________________
Contract No.: _________________ Amount of contract: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
23.c Have any liquidated damages or penalties been imposed by the Commonwealth of Pennsylvania on your organization? (Duplicate page as needed) YES □ NO □
If Answer is yes, please state: Name of agency that took such action: __________________________________________
Date(s) of the action: _____________
Type of work to which the liquidated damages were applied: __________________________
Reasons stated by the agency for the action: _______________________________________
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: _____________________________________________________________________
Prequalification Forms 43 of 51
____________________________________________________________________________
____________________________________________________________________________
Project name: _______________________________________
Contract No.: _________________ Amount of contract: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the action: _____________
Type of work to which the liquidated damages were applied: __________________________
Reasons stated by the agency for the action: _______________________________________
____________________________________________________________________________
____________________________________________________________________________
Project name: _______________________________________
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: _____________________________________________________________________
Prequalification Forms 44 of 51
Contract No.: _________________ Amount of contract: ____________________
Name of agency that took such action: __________________________________________
Date(s) of the 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: ____________________
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: __________________________________________
Grounds asserted by Claimant: __________________________________
Disposition of the matter: ______________________________________
____________________________________________________________
Name of Claimant: __________________________________________
Grounds asserted by Claimant: __________________________________
Disposition of the matter: ______________________________________
____________________________________________________________
Name of Claimant: __________________________________________
Grounds asserted by Claimant: __________________________________
Disposition of the matter: ______________________________________
____________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 45 of 51
Name of Claimant: __________________________________________
Grounds asserted by Claimant: __________________________________
Disposition of the matter: ______________________________________
____________________________________________________________
Name of Claimant: __________________________________________
Grounds asserted by Claimant: __________________________________ Disposition of the matter: ______________________________________
____________________________________________________________
Name of Claimant: __________________________________________
Grounds asserted by Claimant: __________________________________ Disposition of the matter: ______________________________________
____________________________________________________________
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: _____________________________________________________________________
Prequalification Forms 46 of 51
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: __________________________
Disposition of matter: ___________________________________________________________
_____________________________________________________________________________
__________________________________________________________________________
Bid Number: __________________ Project Owner: ___________________________
Disposition of matter: ________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
Bid Number: __________________ Project Owner: ___________________________
Disposition of matter: ___________________________________________________________
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Bid Number: __________________ Project Owner: ___________________________
Disposition of matter: ________________________________________________________
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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: _____________________________________________________________________
Prequalification Forms 47 of 51
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 2: Name: _______________________ Telephone Number: ____________________________________
Reference 3: Name: ________________________ Telephone Number: ___________________________________
Contract Number: _______________________ Amount of contract: ____________________________________
Contracting Agency: _______________________ Location of project: ____________________________________
Reference 1: Name: _______________________ Telephone Number: ____________________________________
Reference 2: Name: _______________________ Telephone Number: ____________________________________
Reference 3: Name: ________________________ Telephone Number: ___________________________________
Contract Number: _______________________ Amount of contract: ____________________________________
Contracting Agency: _______________________ Location of project: ____________________________________
Reference 1: Name: _______________________ Telephone Number: ____________________________________
Reference 2: Name: _______________________ Telephone Number: ____________________________________
Reference 3: Name: ________________________ Telephone Number: ___________________________________
Contract Number: _______________________ Amount of contract: ____________________________________
Contracting Agency: _______________________ Location of project: ____________________________________
Reference 1: Name: _______________________ Telephone Number: ____________________________________
Reference 2: Name: _______________________ Telephone Number: ____________________________________
Reference 3: Name: ________________________ Telephone Number: ___________________________________
Contract Number: _______________________ Amount of contract: ____________________________________
Contracting Agency: _______________________ Location of project: ____________________________________
Reference 1: Name: _______________________ Telephone Number: ____________________________________
Reference 2: Name: _______________________ Telephone Number: ____________________________________
Reference 3: Name: ________________________ Telephone Number: ___________________________________
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: _____________________________________________________________________
Prequalification Forms 48 of 51
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: _____________________________
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: _____________________________
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: _____________________________
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: _____________________________
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: ____________________________
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: _____________________________________________________________________
Prequalification Forms 49 of 51
27. List any equipment owned by your organization that is available for the proposed work: (Duplicate page as needed)
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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: _____________________________________________________________________
Prequalification Forms 50 of 51
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.
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: _____________________________________________________________________
Prequalification Forms 51 of 51
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 _________________