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HomeMy WebLinkAboutContract #: 004472 - From: To: - Exception - ExceptionSchool Department Administration Building North Andover, MA FORM OF SUB -BID To All General Bidders Except those Excluded: /`'•��i�►4'� din Kang Associates, Inc. January 2, 2014 A. The undersigned proposes to furnish all labor and materials required for completing, in accordance with the hereinafter /describedd plans, specifications and addenda, all work specified in OZYJ—1 01.441 09S 34b of the specifications and in any plans specified in such section, prepared by Kang Associates, Inc. for the School Department Administration Building,North Andover, MA for the contract sum of: to V Koars ($ 7_i!, 000 G C� For Alternate #1: Deduct $ " dollars ($ ). For Alternate #2: Add/ Deduct $ / dollars ($ ). For Alternate #3:v Deduct $ !1At� .�ir'GC? .J� CP1 Gdollars ($ �OV O , <i v ). For Alternate #4: /► , Deduct $ dollars ($ For Alternate #5: Deduct $ dollars ($ B. This sub -bid includes addenda numbered ` C. This sub -bid ❑ may be used by any general bidder except: ❑ may only be used by the following general bidders: (To exclude general bidders, insert an "X" in one box only and fill in blank following that box. Do not answer C if no general bidders are excluded.) FORM OF SUB -BID -1 School Department Administration Building North Andover, MA Kang Associates, Inc. January 2, 2014 D. The undersigned agrees that, if he is selected as sub -bidder, he will within five days, Saturdays, Sundays, and legal holidays excluded, after presentation of a subcontract by the general bidder selected as the general contractor, execute with such general bidder a subcontract in accordance with the terms of this sub -bid, and contingent upon the execution of the general contract, and, if requested so to do in the general bid by such general bidder, who shall pay the premiums therefor, or if pre -qualification is required pursuant to section 44D 3/4, furnish a performance and payment bond of a surety company qualified to do business under the laws of the Commonwealth and satisfactory to the awarding authority in full sum of the subcontract price. E. The names of all persons, firms and corporations furnishing to the undersigned labor or labor and materials for the class or classes or part thereof work for which the provisions of the section of the specifications for this sub -trade requires a listing in this paragraph, including the undersigned if customarily furnished by persons on his own payroll and in the absence of a contrary provisions in the specifications, the name of each such class of work or part thereto and the Bid price for such class of work or part thereof are: Name Class of Work Bid Price (Do not give F. The undersigned agrees that the above list of bids to the undersigned represents bona fide bids based on the hereinbefore described plans, specifications and addenda and that, if the undersigned is awarded the contract, they will be used for the work indicated at the same amounts stated, if satisfactory to the awarding authority. G. The undersigned further agrees to be bound to the general contractor by the terms of the hereinbefore described plans, specifications, including all general conditions stated therein, and addenda, and to assume toward him all the obligations and responsibilities that he, by those documents, assumes toward the owner. H. The undersigned offers the following information as evidence of his qualifications to perform the work as bid upon according to all the requirements of the plans and specifications: 1. Have been in business under present business name years. 2. Ever failed to complete any work awarded? 0 3. List one or more recent buildings with names of the general contractor and architect on which you served as a subcontractor for work of similar character as required for the above named buildings. Building Architect . General Co actor Amount of Contract (a A©t .Q db felboL�- esu gam coo pozlor FORM OF SUB -BID - 2 School Department Administration Building Kang Associates, Inc. North Andover, MA _ January 2, 2014 (b) �ClP�,t/1-rG��.� t -0, 00 0 (c) /y ���L� /y0�? ,� �/, CVO 40 4. Bank reference The undersigned hereby certifies that he is able to furnish labor that can work in harmony with all other elements of labor employed or to be employed on the work; that all employees to be employed at the worksite will have successfully completed a course in construction safety and health approved by the United States Occupational Safety and Health Administration that is at least 10 hours in duration at the time the employee begins work and who shall furnish documentation of successful completion of said course with the first certified payroll report for each employee; and that he will comply fully with all laws and regulations applicable to awards of subcontracts subject to section 44F. The undersigned further certifies under penalties of perjury that this sub -bid is in all respects bona fide, fair and made without collusion or fraud with any other person. As used in this subsection the word "person" shall mean any natural person, joint venture, partnership, corporation or other business or legal entity. The undersigned further certifies under penalty of perjury that the said undersigned is not presently debarred from doing public construction work in the commonwealth under the provisions of section twenty-nine F of chapter twenty-nine, or any other applicable debarment provisions of any other chapter of the General Laws or any rule or regulation promulgated thereunder. Date SUB -BIDDER'S CHECKLIST: C/ Addenda Recognized v Bid Deposit DCAM Certificate of Eligibility Sub -Bidder Update Statement y Certificate of Corporate Bidder (Name of Sub -Bidder) By: -24! Si ature and Title of Person nSnSigning d � � Ste, n-�./l !/>✓✓ Business Address City d State FORM OF SUB -BID - 3 N. r School Department Administration Building North Andover, MA CERTIFICATE OF CORPORATE BIDDER Kang Associates, Inc. January 2, 2014 certify that 1 am the of the corporation named as Bidder in the Bid Form, and that / who signed the Bid Form on �� behalf of the Bidder was then the of said corporation and that I know his signature; that hi ignature thereto is genuine and that the Bid Form was duly signed, sealed and executed for and in behalf of said corporation by authority of its governing body. &0/� Corporate Seal If o avllmi /'. c Secretary -Clerk I/ 2 111q Dat CORPORATE BIDDER - 1 AAS NAS SURETY GROUP CONTRACTOR: (Name, legal status and address) MDM Engineering, Inc. 51 Sawmill Road Dudley, MA 01571 OWNER: (Name, legal status and address) Town of North Andover 120 Main Street North Andover, MA 01845 BOND AMOUNT: FIVE PERCENT OF BID 5% PROJECT: (Name, location or address, and Project number, if any) School Department Administration Building BID BOND SURETY: North American Specialty Insurance Company 475 N. Martingale Road, Suite 850 Schaumburg, IL 60173 This document has important legal consequences. Consultation with an attorney is encouraged with respect to its completion or modification. Any singular reference to Contractor, Surety, Owner or other party shall be considered plural where applicable. The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which the Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns, jointly and severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the bid of the Contractor within the time specified in the bid documents, or within such time period as may b� agreed to by the Owner and Contractor, and the Contractor either (1) enters into a contract with the Owner in accordance with the terms of such bid, and gives such bond or bonds as may be specified in the bidding or Contract Documents, with a surety admitted in the jurisdiction of the Project and otherwise acceptable to the Owner, for the faithful performance of such Contract and for the prompt payment of labor and material furnished in the prosecution thereof, or (2) pays to the Owner the difference, not to exceed the amount of this Bond, between the amount specified in said bid and such larger amount for which the Owner may in good faith contract with another party to perform the work covered by said bid, then this obligation shall be null and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of an agreement between the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time for acceptance of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's consent for an extension beyond sixty (60) days. If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this Bond shall be deemed to be Subcontractor and the term Owner shall be deemed to be Contractor. When this Bond has been furnished to comply with a statutory or other legal requirement in the location of the Project, any provision in this Bond conflicting with said statutory or legal requirement shall be deemed deleted herefrom and provisions conforming to such statutory or other legal requirement shall be deemed incorporated herein. When so furnished, the intent is that this Bond shall be construed as a statutory bond and not as a common law bond. Sig ed and se ed this 21st day of January 2014 fitness) (QW&& (wl SS) loce yn Keech, Bond Administrator This Document conforms to the AIA Document A310TM— 2010 MDM Engineering, Inc. (Principal) �/ (Seal) (Title) Zbig4ew Mroczka, President North Americ2acialtv Insurance Company (Surety) �� f ` (Seal) (Title) Joseph M. Phillips, Attorney -In -Fact NAS SURETY GROUP NORTH AMERICAN SPECIALTY INSURANCE COMPANY WASHINGTON INTERNATIONAL INSURANCE COMPANY GENERAL POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS, THAT North American Specialty Insurance Company, a corporation duly organized and existing under laws of the State of New Hampshire, and having its principal office in the City of Manchester, New Hampshire, and Washington International Insurance Company, a corporation organized and existing under the laws of the State of New Hampshire and having its principal office in the City of Schaumburg, Illinois, each does hereby make, constitute and appoint: MARIA GADZIALA, JOCELYN KEECH and JOSEPH PHILLIPS JOINTLY OR SEVERALLY Its true and lawful Attomey(s)-in-Fact, to make, execute, seal and deliver, for and on its behalf and as its act and deed, bonds or other writings obligatory in the nature of a bond on behalf of each of said Companies, as surety, on contracts of suretyship as are or may be required or permitted by law, regulation, contract or otherwise, provided that no bond or undertaking or contract or suretyship executed under this authority shall exceed the amount of: FIFTY MILLION ($50,000,000.00) DOLLARS This Power of Attorney is granted and is signed by facsimile under and by the authority of the following Resolutions adopted by the Boards of Directors of both North American Specialty Insurance Company and Washington International Insurance Company at meetings duly called and held on the 9'h of May, 2012: "RESOLVED, that any two of the Presidents, any Managing Director, any Senior Vice President, any Vice President, any Assistant Vice President, the Secretary or any Assistant Secretary be, and each or any of them hereby is authorized to execute a Power of Attorney qualifying the attorney named in the given Power of Attorney to execute on behalf of the Company bonds, undertakings and all contracts of surety, and that each or any of them hereby is authorized to attest to the execution of any such Power of Attorney and to attach therein the seal of the Company; and it is FURTHER RESOLVED, that the signature of such officers and the seal of the Company may be affixed to any such Power of Attorney or to any certificate relating thereto by facsimile, and any such Power of Attorney or certificate bearing such facsimile signatures or facsimile seal shall be binding upon the Company when so affixed and in the future with regard to any bond, undertaking or contract of surety to which it is attached." \`�wluuaJn��/ \AQ�G1AllTY�li4//��� StON 1 y :.�pPOq�T G9p % • G R :SvZ! B y oa�aannnnairyr Ql .. NAI, oQ �4i: ORPO/'•.sG �n 2:' G TF'•. j SERI O = Steven P. Anderson, Senior Vice President of Washington International Insurance Company Z; SEAL a Wi4,. 1973 Qry tj ^ & Senior Vice President of North American Specialty Insurance Company O. jm ,= � Ili1U������ ' �mt By David M. Layman, Vice President off Washington International Insurance Company & Vice President of North American Specialty Insurance Company IN WITNESS WHEREOF, North American Specialty Insurance Company and Washington International Insurance Company have caused their official seals to be hereunto affixed, and these presents to be signed by their authorized officers this29th day of April , 2013 . North American Specialty Insurance Company Washington International Insurance Company State of Illinois County of Cook ss: On this 29th day of April 2013 , before me, a Notary Public personally appeared Steven P. Anderson , Senior Vice President of Washington International Insurance Company and Senior Vice President of North American Specialty Insurance Company and David M. Layman , Vice President of Washington International Insurance Company and Vice President of North American Specialty Insurance Company, personally known to me, who being by me duly sworn, acknowledged that they signed the above Power of Attorney as officers of and acknowledged said instrument to be the voluntary act and deed of their respective companies. "OFRCIALSEAL" DONNA D. SKLENS Notary Public, State of Illinois Donna D. Sklens, Notary Public My Commission Expires 10/06/2015 1, Jeffrey Goldberg , the duly elected Assistant Secretary of North American Specialty Insurance Company and Washington International Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney given by said North American Specialty Insurance Company and Washington International Insurance Company, which is still in full force and effect. IN WITNESS WHEREOF, I have set my hand and affixed the seals of the Companies this 121 day of �aalf � , 20 1 _I Jeffrey Goldberg, Vice President & Assistant Secretary of Washington International Insurance Company & North American Specialty Insurance Company EFFECTIVE MARCH 30, 2010 Commonwealth of Massachusetts Division of Capital Asset Management SUB -BIDDER UPDATE STATEMENT TO ALL SUB -BIDDERS, TRADE CONTRACTORS AND AWARDING AUTHORITIES A COMPLETED AND SIGNED SUB -BIDDER UPDATE STATEMENT MUST BE SUBMITTED WITH EVERY FILED SUB -BID PURSUANT TO M.G.L. c.149, §44F AND EVERY TRADE SUB -BID PURSUANT TO M.G.L. c. 149A. ANY FILED SUB -BID OR TRADE SUB -BID SUBMITTED WITHOUT AN APPROPRIATE SUB -BIDDER UPDATE STATEMENT IS INVALID AND MUST BE REJECTED. Caution: This form is to be used for submitting Filed Sub -Bids and Trade Sub -Bids. It is not to be used for submitting Prime/General Contract bids, AWARDING AUTHORITIES If the Awarding Authority determines that the sub -bidder is not competent to perform the work as specified on the project, it should reject the bid. SUB -BIDDER'S AFFIDAVIT I swear under the' pains and penalties of perjury that I am duly authorized by the bidder named below to sign and submit this Sub -bidder Update Statement on behalf of the bidder named below, that I have read this Sub -bidder Update Statement, and that all of the information. provided by the bidder in this Sub -bidder Update Statement is true, accurate, and complete as of the bid date. ___dv/J :� , F'00 Bid ate Print Name of b -bidder or rade Contractor Business Address 14 o -L s . h%/o,: Project Nu ber (or / name if no number) '5 ) e - 9 AK/ Awarding Authority Teleph ne Number SIGNATURE* �f li1i�.• �- Bidde s Authorized Representative Division of Capital Asset Management Page 1 of 10 A, IF t� i " ri��cilir�r �'tcr {1' ('A&1bWjbfl,1i00 01411/ :h�1r{irrr�� °;�� __,aN'J` f.'/'//{� t,rLarfr/1•Li(1II :l �IIC.Q DEVAL L. PATRICK �Jl(�J�{lit, cJl"F{/t1�3/IG11fIJP�I4 0208 GOVERNOR (6/7) 7?7­`f ;0 TIMOTHY P. MURRAY .'/rmt: i15'/7i 727-7,161 LIEUTENANT GOVERNOR Sub -Bidder Certificate of Eligibility Contractor: MDM Engineering Company, Inc. 51 Sawmill Road Dudley MA 01571 This Certificate Shall Be Used For Submitting Filed Sub -Bids Only JAY GONZALEZ SECRETARY. ADMINISTRATION & FINANCE CAROLE CORNELISON COMMISSIONER 1516 In accordance with M.G.L. Chapter 149, Section 44D and 810 CMR 4.00, you are hereby certified to rile sub - bids under Chapters 149 and 149A in the following categories: Roofine Flashing The average numerical value on projects evaluated by DCAM: 96 Masonry Work Waterproofing, Damp Proofing, 621 Number of prior construction projects evaluated by DCAM on this sub -bidder: 18 Number of projects given numerical values below a passing score: 1 This certificate is valid from 4/18/2012 to 4/18/2013 S�I!; Freya S. Berfistein,-6eputy General Counsel, Date for Carole J. Cornelison, Commissioner Official DCAM Amendments Date Authorization Extension to: Name: Work Category: Address Change: INSTRUCTIONS INSTRUCTIONS TO BIDDERS • This form must be completed and submitted by all Prime/General contractors bidding on projects pursuant to M.G.L. c. 149, §44A and M.G.L. c. 149A. • You must give complete and accurate answers to all questions and provide all of the information requested. MAKING A MATERIALLY FALSE STATEMENT IN THIS UPDATE STATEMENT IS GROUNDS FOR REJECTING YOUR BID AND FOR DEBARRING YOU FROM ALL PUBLIC CONTRACTING. This Update Statement must include all requested information that was not previously reported on the Application used for your firm's most recently issued (not extended or amended) Prime/General Contractor Certificate of Eligibility. The Update Statement must cover the entire period since the date of your Application, NOT since the date of your Certification. You must use this official form of Update Statement. Copies of this form may be obtained from the awarding authority and from the Asset Management Web Site: www.mass.gov/dcam. If additional space is needed, please copy the appropriate page of this Update Statement and attach it as an additional sheet. See the section entitled "Bidding Limits" in the Instructions to Awarding Authorities for important information concerning your bidding limits. INSTRUCTIONS TO AWARDING AUTHORITIES Determination of Bidder Qualifications It is the awarding authority's responsibility to determine who is the lowest eligible and responsible bidder. You must consider all of the information in the low bidder's Update Statement in making this determination. Remember: this information was not available to the Division of Capital Asset Management at the time of certification. The bidder's performance on the projected listed in Parts 1 and 2 must be part of your review. Contact the project references. AWARDING AUTHORITIES ARE STRONGLY ENCOURAGED TO REVIEW THE LOW BIDDER'S ENTIRE CERTIFICATION FILE AT THE DIVISION OF CAPITAL ASSET MANAGEMENT. Telephone (617) 727-9320 for an appointment. Bidding Limits Single Proiect Limit: The total amount of the bid, including all alternates, may not exceed the bidder's Single Project Limit. Aggregate Work Limit: The annual value of the work to be performed on the contract for which the bid is submitted, when added to the annual cost to complete the bidder's other currently held contracts, may not exceed the bidder's Aggregate Work Limit. Use the following procedure to determine whether the low bidder is within its Aggregate Work Limit: Step 1 Review Update Statement Question #2 to make sure that all requested information is provided and that the bidder has accurately calculated and totaled the annualized value of all incomplete work on its currently held contracts (column 9). Step 2 Determine the annual dollar value of the work to be performed on your project. This is done as follows: (i) If the project is to be completed in less than 12 months, the annual dollar value of the work is equal to the full amount of the bid. (ii) If the project will take more than 12 months to complete, calculate the number of years given to complete the project by dividing the total number of months in the project schedule by 12 (calculate to 3 decimal places), then divide the amount of the bid by the calculated number of years to find the annual dollar value of the work. Step 3 Add the annualized value of all of the bidder's incomplete contract work (the total of column 9 on page 5) to the annual dollar value of the work to be performed on your project. The total may not exceed the bidder's Aggregate Work Limit. Correction of Errors and Omissions in Update Statements Matters of Form: An awarding authority shall not reject a contractor's bid because there are mistakes or omissions of form in the Update Statement submitted with the bid, provided the contractor promptly corrects those mistakes or omissions upon request of the awarding authority. (810 CMR 8.05(1)). Correction of Other Defects: An awarding authority may, in its discretiorf, give a contractor notice of defects, other than mistakes or omissions of form, in the contractor's Update Statement, and an opportunity to correct such defects, provided the correction of such defects is not prejudicial to fair competition. An awarding authority may reject a corrected Update Statement if it contains unfavorable information about the contractor that was omitted from the Update Statement filed with the contractor's bid. 1810 CMR 8.05(2)). 4 - Division of Capital Asset Management Page 2 of 10 Prime/General Contractor Update Statement Effective March 30, 2010 i to 3. c, o' CD o m �0) 0 w. 0 :3 D N 0 cv m� m m mCD 3 m m m 0 W 0 N 0 CO D 0 o v a — N —a =r a m m CD CD co v � 0 m Ena x � o 3 v� m0 ..0. 0 O < 0 a 0. cD 3 a� M 0 cD D -00 CD w 0 0 s� �0 C=r CL 0 C �Q 0 CD 0c CD Q. 0 0 0 0. 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O � C `J U `t V V � � a Q °. c E W � N O o O YLL LU\1 k o`° L O z 41 =+ T O z v� �" o 3 F- (n� L Q i- ( 0 O o C C QQ C N Q 0 a- M N z c cp L w U Q > O C: U O V `� M W ry Z D' Z Z Z 2 L Z w Z L N O p IWL W (DW (DW (Dw CD � W (DO Z Z Z Z Z Zcps cp 0 of w U� w U� w v� w U� w w v Z) c C o o (D0 o Cho o (D0 o (D0 o (D0 o ) o� o Y z (n^` (p ^Q >C: 0 d7 J �' �'1 � t�UII OL ~ O C N O E- `, a C O O 7n U cu E L Q3 WO O ac m Q L U C C L D W 0, C N E O O cn ov Q ov Q_ n PART 3 - PROJECT PERFORMANCE For Parts 3 and 4, if you answer YES to any question, please provide on a separate page a complete explanation. Information you provide herein must supplement the Application for your most recently issued (not extended or amended) DCAM Certificate of Eligibility. You must report all requested information not previously reported on that DCAM Application for Prime/General Certificate of Eligibility. Include all details (project name(s) and location(s), names of all parties involved, relevant dates, etc.]. YES NO I . Has your firm been terminated on any contract prior to completing a project or has ❑ any officer, partner or principal of your firm been an officer, partner or principal of another firm that was terminated or failed to complete aproject? 2. Has your firm failed or refused either to perform or complete any of its work under ❑ any contract prior to substantial completion? 3. Has your firm failed or refused to complete any punch list work under any contract? ❑ 4. Has your firm filed for bankruptcy, or has any officer, principal or individual with a ❑ financial interest in your current firm been an officer, principal or individual with a financial interest in another firm that filed for bankruptcy? 5. Has your surety taken over or been asked to complete any of your work under any ❑ contract? 6. Has a payment or performance bond been involved against your current firm, or has ❑ any officer, principal or individual with a financial interest in your current firm been an officer, principal or individual with a financial interest in another firm that had a payment or performance bond invoiced? 7. Has your surety made payment to a materials supplier or other party under your ❑ payment bond on any contract? 8. Has any subcontractor filed a demand for direct payment with an awarding authority ❑ for a public project on any of your contracts? 9. Have any of your subcontractors or suppliers filed litigation to enforce a mechanic's ❑ lien against property in connection with work performed or materials supplied under any of your contracts? 10. Have there been any deaths of an employee or others occurring in connection with ❑ any of your projects? 1 1. Has any employee or other person suffered an injury in connection with any of your ❑ projects resulting in their inability to return to work for a period in excess of one year? Division of Capital Asset Management Page 7 of 10 Prime/General Contractor Update Statement Effective March 30, 2010 PA'kT 4 -'Legal or Administrative Proceedings; Compliance with Laws Please answer the following questions. Information must supplement all judicial and administrative proceedings involving bidder's firm, which were instituted or concluded (adversely or otherwise) since your firm's Application for your most recently issued (not amended or extended) Certificate of EIigibility. You must report all requested information not previously reported on that DCAM Application for Prime/General Certificate of Eligibility. The term "administrative proceeding" as used in this Prime/General Contractor Update Statement includes (i) any action taken or proceeding brought by a governmental agency, department or officer to enforce any law, regulation, code, legal, or contractual requirement, except for those brought in state or federal courts, or (ii) any action taken by a governmental agency, department or officer imposing penalties, fines or other sanctions for failure to comply with any such legal or contractual requirement. The term "anyone with a financial interest in your firm" as used in this Section "I", shall mean any person and/or entity with a S% or greater ownership interest in the applicant''s firm. if you answer YES to any question, on a separate page provide a complete explanation of each proceeding or action and any judgment, decision, fine or other sanction or result. Include all details (name of court or administrative agency, title of case or proceeding, case number, date action was commenced, date judgment or decision was entered, fines or penalties imposed, etc.). YES NU 1. Have any civil, judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to the procurement or performance of any construction contract, including but not limited to actions to obtain payment brought by subcontractors, su liers or others? 2. Have any criminal proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to the procurement or performance of any construction contract including, but not limited to, any of the following offenses: fraud, graft, embezzlement, forgery, bribery, falsification or destruction of records, or receipt of stolen property? 3. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of any state's or federal procurement laws arising out of the submission of bids or proposals? 1. Have any judicial or administrative proceedings involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of M.G.L. Chapter 268A, the State Ethics Law? Division of Capital Asset Management Page 8 of 10 Prime/General Contractor Update Statement Effective March 30, 2010 . PART 4 - Legal or Administrative Proceedings; Compliance with Laws (continued) YES NO 5. Have any judicial or administrative proceedings involving your firm or a principal ❑ or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of any state or federal law regulating hours of labor, unemployment compensation, minimum wages, prevailing wages, overtime pay, equal pay, child labor or worker's compensation? 6. Have any judicial or administrative proceedings involving your firm or a principal ❑ or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of any state or federal law prohibiting discrimination in employment? 7. Have any judicial or administrative proceedings involving your firm or a principal ❑ or officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a claim of repeated or aggravated violation of any state or federal law regulating labor relations? 8. Have any proceedings by a municipal, state, or federal agency been brought, ❑ concluded, or settled relating to decertification, debarment, or suspension of your firm or any principal or officer or anyone with a financial interest in your firm from public contracting? 9. Have any judicial or administrative proceedings involving your firm or a principal or ❑ officer or anyone with a financial interest in your firm been brought, concluded, or settled relating to a violation of state or federal law regulating the environment? 10. Has your firm been fined by OSHA or any other state or federal agency for ❑ violations of any laws or regulations related to occupational health or safety? Note: this information may be obtaiDed from OSHA's Web Site at www.osha.gov 1 1. Has your firm been sanctioned for failure to achieve DBE/MBE/WBE goals, ❑ workforce goals, or failure to file certified payrolls on any publicprojects? 12. Other than previously reported in the above paragraphs of this Section 1, have any ❑ administrative proceedings or investigations involving your firm or a principal or officer or anyone with a financial interest in your firm been brought, concluded, or settled by any local, state or federal agency relating to the procurement or performance of any construction contract? l 3. Are there any other issues that you are aware which may affect your firm's ❑ responsibility and integrity as a building contractor? 4I Division of Capital Asset Management Page 9 of 10 PrimelGeneral Contractor Update Statement Effective March 30, 2010 PART 5 - SUPERVISORY PERSONNEL List all supervisory personnel, such as project managers and superintendents, who will be assigned to the project if your firm is awarded the contract. Attach the resume of each person listed below. NAME TITLE OR FUNCTION PART 6 - CHANGES IN BUSINESS ORGANIZATION OR FINANCIAL CONDITION Have there been any changes in your firm's business organization, financial condition or bonding capacity since the date your current Certificate of Eligibility was issued? ❑ Yes ('No If YES, attach a separate page providing complete details. PART 7 — LIST OF COMPLETED CONSTRUCTION PROJECTS SUBMITTED TO THE DIVISION OF CAPITAL ASSET MANAGEMENT. Attach here a copy of the list of completed construction projects which was submitted with your firm's DCAM Application for your most recently issued (not extended or amended) DCAM Certificate of Eligibility. The Attachment must include a complete copy of the entire Section G — "Completed Projects" and the ficial page — "Certification" (Section J) containing the signature and date that the Completed Projects list (Section G) was submitted to the Division of Capital Asset Management. Division of Capital Asset Management Page 10 of 10 Prime/General Contractor Update Statement Effective March 30, 2010 E. . 'Highest Value Projects Experience Indicate the two highest value single building contracts completed by your firm within the past five years including start and end dates, names, addresses, and telephone numbers of owners, designers, and general contractors (or their representatives). When listing requested Categories of Work, refer to categories from page 9 of this application. If a contract included more than one Category of Work for which your finn seeks certification, and the work was performed by your firm's own employees, please provide dollar breakdowns attributable to each category of work separately. Do not list highway, bridge, tunnel, sewer, site work, or other horizontal projects that do not involve buildings. Highest Single Project: `IS6on `r kW -Ada [] Project Title:1?e !,;1GY/Je1 AOA9/4Po4 Enter all appropriate C o(s) of Work (from page 9) and include a dollar breakdown for each category: Category / /%2 L' !. 7 Category 2)lkajale Category 3) lel flop Total Contract Amount: [w) It'applying for General Building Construction, list the three (3) largest building -related sub -trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ -. 2. $ D. $ Project Location (city & state): Start / End dates: 7—pf/ l(>_ O,Y Contact Person:,A,/,. &1 ae / `eJ �e,'41 ._ Telephone Number: elll 2 .3y' l03.s Complete Mailing Ad els•/.Y Al elp' o63s/ This project was managed by a: (:'onstruction Manager ❑ General Contractor ❑ .architect/Designer Nlcheck one) Name of Firmvv�,r�l'`�• �' �'��'es Contact Person: /J7 -1 d aceeweojle/ l Telephone Number: Op6Q — �o/ op— J� 2/ Complete Mailing Address: Second Highest Building Protect: M Project Title e,, -//? N S(%co Enter all appropriate Categorie() of Work (from page 9) and include a dollar breakdown for each category: �.� O� ° Category 1) � f DdO Category 2) Category $ �D� p � PO Total Contract Amount: $ .�/ �J d If applying for General Building Construction, list the three (3) largest building -related sub -trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ ,� 1--ln - / '/- 0�037 Project Location (city & state):`e,*/;2p/vJ1 `/If - Start / End dates:/4W/— �. �� Owner: f'a��l d Contact Person: Ste /O Oe /'h Onf f 91 Telephone Number: Complete Mailing A ress: go . This project was managed by a: Construction Manager 11 General Contractor C Architect/Designex(check one) Name of Firm: �► Contact Person: /�/�r Aa h oa7 Telephone Number: Complete Mailing Address: Page 12 of 36 Prime/General Revised January 2009 F. Projects in Progress t. . List'all building construction projects your firm has in process on this date that are at least $80,000. Do not list projects with contract values of less than $80,000. If your firm has more than twenty (20) projects in process on this date, please restrict your list to the twenty oldest contracts still in process. Information on randomly selected projects is not acceptable. Answer all questions. When listing requested Categories of Work, refer to categories from page 9 of this application and list all relevant categories of work which your firm performed with its own employees for each project. With respect to single contracts involving multiple categories of work, provide a dollar breakdown attributable to each category listed. Do not list highway, bridge, tunnel, sewer, site work, or other horizontal projects that do not involve buildings. Attach additional sheets, if necessary. Project Title: A grow 1611 4W A� Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: `LG� 5p/ o . Category I $ i Category 2),& /AQ S Category 3)`ov090"j 9C 0 m d Total Contract Ant: $ A OS/4 3 O . [] If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state,: Start / End dates: l/— - S -- 2I — !Z Percent Complete; % Owner: /v'40V of f o! Contact Person:er4A'Q/ 'R14h q�I rosy- cp Telephone Number:�� 69%Ale' ,� Complete Mailing Addres This project is managed by a: Construction Manager LEI General Contractor ❑ Architect/Designey4" e k e) Name of Firm: L Contact Person: /Oqk • Telephone Number: ;W, Complete Mailing Address: _��ile �OoP C9 3 /v JV — 1A111— 6) �2 / 3 Y. 2. Project Title: Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) $ Category 2) $ Category 3) $ Total Contract Amount: $ ® If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Start / End dates: / Percent Complete: % Owner: Contact Person: Telephone Number: Complete Mailing Address: This project is managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designer ❑ (check one) Name of Firm: Contact Person: Telephone Number: Complete Mailing Address: Page 13 of 36 Prime/General Revised January 2009 I Completed Projects List all building construction projects of at least $80,000, which your firm has completed within the past five years or the twenty most recent projects completed within the past five years that are at least $80,000. Do not list projects with contract values less than $80,000. Information on randomly selected projects is not acceptable. Note: when listing requested Categories of Work, refer to categories from page 9 of this application. List all relevant. categories of work that your firm performed with its own employees for each project. With respect to single contracts involving multiple categories of work, provide a dollar breakdown attributable to each category listed. Do not list highway, bridge, tunnel, sewer, site work, or other horizontal projects that do not involve /buildings. Attach additional sheets, if necessary. Project Title: �OATbbl-10//ro Rldlol1L0J project Title: li��t�/1e�G 'V/�l�l Enter all appropriate Categorie(s) of Work (from Enter all appropriate Categorie(s) of Work (fr m page 9) and include a dollar breakdown for each page 9) and include a dollar breakdown for each category: -. category: Category I )R - $ ��` � Category I ) Gtr `lll Category 2)i4i /Q�,2✓��, 3 2 Category 2) $ Category 3)�u�� IGQ. 000 Category 3) $ Total ContractAmgd�nt: $/.O g.302 Total Contract Amount: $15f - If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: I. $ 2. $ 3. $ Project Location (city & state): Start / End dates: Owner: /OW x> CV SLfhhti► al q�'/�'� Contact PersonAl" % Z a ll _� p O l Telephone Number: SD4— 23 feO' Complete Mailing Address: r1llarIN , &h IM; 7SGI Me- 1117— 0IS, P This project was managed by a: Construction Manager El General Contractor O Architect/Designer j�(check one) Name of Firm: r7 1�� �� Contact Person: /V/-. 1 -G V kc/ , l Telephone Number: �,. ? Z$'... Complete Mailing Ad ess: If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state :'Cuo"l�Ge Start / End dates:/{ /—,awe — / Owner: Contact Person: /19G, Xle ��!3 Telephone Number: e �Y Complete Mailing Address:,%j'— OeW zolwe_ This project was managed by ate: Construction Manager ❑ General Contractor El Architect/Designer'(check one) 1.2 Name of Firm: Contact Person: �a/0/- Telephone Number: W 1Z Complete Mailing Address: /6SL•6e<�y 1�w�/o�- oo1/Li- i`/F1-o2/6,f Page 23 of 36 Prime/General Revised January 2009 U G.. Completed Projects (continued,)) fes,/e 3_ Project Title4p��PJ�� Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) Category 2) $ Category 3) $ Total Contract Amount: $? lrl7 0, 0 3 / ;; v If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ - 2• $ 3. $ Project Location (city & state): L P/?P-;' �/'�� Start / End dates: ;FAY- //—Zo — Owner: �C/ll�%�PG �'�✓` ` !IOOIJ �lG. sash ' Contact Person: rf0 rld Telephone Number !0 `%O/ ` oz1;7,V Complete Mailin Addres4! This project was managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designe(check one) Name of Firm: 61-drO 14Y Contact Person:/ /4. /%CA W1;2C?0 '� Telephone Numbet: V-1, yl/e_ 17 e 5_3 Complete Mailing Address: 0 o �j o!n!d �oui &���P/a /- hfi Page 24 of 36 Prime/General Revised January 2009 4. Project Title: /�IL� '/ �20o,- / Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: �O y C;70 v Category 1) Lvt/. $ Category 2) $ Category 3) $ Total Contract Amount: V'Q C71 00 0 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Start / En//d ,dates: l/-/— —O Owner:Y�PJh1tPCv//Y o`s,�Vsy, Contact Person: At. Telephone Number: '�//J Complete Mailing Address: 1,V AeY! 1.1- MAle %< This project was managed by a: Construction Manager D General Contractor ❑ Architect/Designer(check one) Name of Firm: &40101zley Contact Person:,4 `,, Telephone Number: 4.1.5 _ Complete Mailing Address: Op A "'.,'1JS�P�/- G. ..'.Completed Projects (continued) 5. Project Title: Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: .� Category 1) GG 0 `3 -3/ Category 2) $ Category 3) $ Total Contract Amount: $ /3S/0q</ If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2• $ 3. $ Project Location (ciDf & state): Start / End dates: el A/ _ / s Owner: J'�lleh' ' �L 4�P '��� G/, Contact Person:/V4. f - /6�.,' 3 G• p� Telephone Number: p'? l� cf Complete Mailing Address:�Gd This project was managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designer,[A check one) �,��h ass. 1t, Name of Firm: d Contact Person:/1�Pq` j?10L e�zw. I'� • l �• Telephone Number: 97or- yy3 _-Y <?3 Complete Mailing Address: Page 25 of 36 Prime/General Revised January 2009 6. Project Title.Zzelee G,(, j46tvor Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category:/ Category �(�!� Category 2) $ Category 3) $ Total Contract Amount: If applying for General Building Construction. list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: I. $ 3. $ Project Location (city & state): �j xo Start / End dates: r JJ Owner: /v A -W o Contact Person:� '6.. Telephone Number: %�/- 00.1%- Complete Mailing Address:gp kWxh1Y27 ro�.�10 - r�-- ©9 This project was managed b Construction Manager ❑ General Contractor Architect/Designerheck one) Name of Firm: k�f1V'�.- '�ga GL Contact Person. 111A. � 6I` z • fw Telephone Number:_ n Complete Mailing Address: L / ' le --"t 010103 G. "Completed Projects (continued) 7' Project Title: tV/e �, J'tl�lOG7 Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each Category 1) � 100-Z ®h Category 2)A"cY! ! — er© ftp d Category 3)/.v wej O C7 Total Contract Amount: $ If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): 460�1�''9% Start / End dates: Owner: .V o4-, Contact Person: Telephone Number: ?7e - oV7- O 21 l Complete Mailing Address: This project was managed by a: Construction Manager 0 General Contractor 0 Architect/Designer�heck one) Name of Firm: kwwzsv Contact Person: Az. Telephone Number: Complete Mailing Address: —3 -3 J� 02-ndf"10o�, O/�o3 Page 26 of 36 PrimetGeneral Revised January 2009 �/XXzo � 8. Project Title: ri Enter all appro riafe Categories) of'Work (from page 9) and include a dollar breakdown for each category: /S/&/ 00 C� Category / Category 2) Category 3)/;�,V0 Total Contract A" .$ If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 1-7 3. $ Project Location (city & state) *m 1311 / j, Start / End dates: 30 —1/� Owner:6Y-r /;l-e"—/n/ &/%d Contact Pefson: OVW. e'O�u/ e Telephone Number: e,!ro Complete Mailing Address: ISO This project was managed by a: Construction Man r ❑ General Contractor ❑ Architect(Designej check one) Name of Firm: /,[ of eulle 13O o je 4 Contact Person: �� ('(�� 0/Gul ��! L !� Telephone Number: ,0'0_ n Complete Mailing Address: °� °2 3 �O %�61ta�< RO / 11,e to 6 / / ;Peo /;,/7 IIT G. • Completed Projects (continued) i 1.Project Title: ilvvtoav Enter all appropriate Categories) of Work (from page 9) and include a dollarbreakdownfor each category: Category 1) . $ Category2) W 44 t�~ — -5-67 Oa Category 3) Total Contract Amount: $ '3—c?31 0� U If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3_ $ 12.Project Title: Enter all appropriate Cat orie s of Work (from page 9) and include a dollar breakdown for each category: c� Category 1) Category 2) $ Category 3) $ Total Contract Amount: $ Z/O 662 U If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): / f ' Siam /End dates: /, `�/���PJ7-/1V Project Location (city & state): c�lv�� /O Start /End dates: � — D— Owner: ro� o; -I let�1�Py �� Owner: 1/0/ Contact Person: A. A01, 01W l� J Telephone Number: lJ�_ G2�1 Contact Person. Az /YGY�1 ���— L%'7 Telephone Number: 040 OWG — 3 Complete Mailing Address,,:��C7 �,�/;Vs b Complete Mailing Address:2 This project was managed by a: ! 2j � �t�' �G6��'t �/� - e7, iJ�O This project was managed by a: Construction Mer ❑ General Contractor ❑ Construction Man Eler ❑ General Contractor Architect/Designenr'(check one) ArchitectlDesigner (check one) Name of Firm -Name Name of Firm: �� s tl U�Zd� �jOa Contact Person:-(�.JI�GC>j�- l�/ !�"Contact Person:, Telephone Number: �OPf 3 33 � �j 453 - Telephone Number: Complete Mailing AddiesT 7 Complete Mailing Address: le �� /�J�Q` �l �� rro�c• Page 28 of 36 Prime/General Revised January 2009 G.' Completed Projects (continued) 13.Project Title: 1-1vt h C"CPCO 1 1�L4 f - Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: ^ �D C2 Category 1) 164-1y. ✓ $ (7 Category 2) $ Category 3) $ Total Contract Amount: $ ,.�p� If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Z -- Project Location (city & state): 1101 C'0e1-/?1*�' Start / End dates: Owner:0Z101nCOC1 �i91 All ja�ocov . Contact Person: &G. 40/400A09 Telephone Number: �f/3 `� .- S3 3 eP Complete Mailing Address: 3G,�b ,TKO/4eoc-/e f^�/ This project was managed by a: Construction Manager ❑ General Contractor ❑ Architect/DesignerA(check one) Name of Firm: Contact Person: /y, Telephone Number: 7/.3 ys'� _5-l3 / Complete Mailing Address: IfIllo /,�? 0�� ©1 2 G% Page 29 of 36 Prime/General Revised January 2009 14.Project Title: wo����'foo -2 �� Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: -1 s� � p Category 1) 4Z -X,/$ 7,.>/, d' Category 2) $ Category 3)/yuSo;01 Total Contract Am unt: $ s`©x P If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ / Project Location (city & state): Start / End dates/.6wt Cbp-- OCT'- Go Owner:1h, 4e Contact Person: iiG, lug Ulw���,% Telephone Number: Complete MailingAddreI��s:G6/!.o e4. A; This project was managed by����� Construction Maner ❑ General Contractor 11Architect/DesignerrTcheck one) Name of Firm,0/`4/,rJ-6,0 Contact Person: IfI4 xi• ew- Telephone Number: Complete Mailing Address: G. Completed Projects (continued) 15.Project Title: Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: O Category 1) Category 2) $ Category 3) $ Total Contract Amount: $ If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: I- $ 2. $ 3. $ Project Location (city & state): Start /End dates:l�—t7_loto Owner: Contact Person: /�'�G • �'/1°r 17 OC Telephone Number: OVO- yS5' Complete Mailing Address: 3 �� WPI Z FO This project w managed by a: Construction Manager ❑ General Contractor ❑ Architect/Designer-(check one) . Name of Firm: 1k L,, V'ir,1- 6eojAea Contact Person: /1G. lwl«hy 17. 111-7Telephone Number: D6� Complete Mailing Address: 16.Project Title: Tzol�heelnl 0J404A Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: Category 1)/ x;� $ G t, C� Category 2) $ Category 3) $ Total Contract Amount: $ If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state)A ,n� f'AA,� Start /End dates: / � � Owner: Contact Person: Telephone Number: 5; �O' _ Complete Mailing Address: ` This project wi��a�nag d bey a� `�—�6®�� Construction Manager ❑ General Contractor ❑ Architect/Designer heck one) Name of Firm: mn"e.Vl PJ'6001'4, o, Contact Person: 1411. l✓l, ky hr, /. 17 Telephone Number: �40 03 � /0_ 3 �� Complete Mailing Address: Ilk o�oso Page 30 of 36 Prime/General Revised January 2009 G: - '.Completed Projects (continued) 1 7.Prcject TitIe:!�6P. 6400 J pool Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: 13i G0 f7 Category 1)4� $ 6 Category 2)<c� G� 2 d p , O C, G Category 3),&0A,, 3 / Total Contract Am6unt: $42e--,Oeo�-, 24 0 0 �15� vb d If applying for General Buitdmg Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Laf9W-&4 Start / End dates: Owner:.yu-44 1 /�tGt.GC�GG �lCLC�G-' Contact Person: 1,�A* /gyp .. xa6 Telephone Number. 203 — 720 Complete Mailing Addresw,����� / C. This project was managed by a: a, Construction Manner 0 General Contractor 0 Architect/Designer check one) Name of Firm: �'p!t°.J7!'��'�1� AW Contact Person: jlf�, f,1��� j �' � � �► Telephone Number: _ 2�y-- 0 � // Complete Mailing Ad ss: G 4 ?/,�Ox � All O�oso Prime/General Revised January 2009 Page 31 of 36 18 -Project Title: �-Jl � Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: Categoryl,/tl 6P(V6,-> Category 2) $ Category 3) $ Total Contract Amount: $ 1701000 If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state):Aw3P4Ah, Start /End dates * //— 12 Owner: / 06w e7 or' or v 1peave— Contact Person: Telephone Number: Complete Mailing Address: ,$e ,4e Joe,, fdj This project was managed by a: Construction Manager 0 General Contractor 0 Architeaffiesigne check one) Name of Firm: A /3 /,0 Contact Person: ;WAIAO(WO-2' Telephone Number: _Y6_ sZ3 ted Complete Mailing A ess: Gyp/ v-jr,�on t{�S <Lrilran %1�✓ �Si/.f.�isu h rn m- AIR G. Completed Projects (continued) 19.Project Title: f.GlClleG Aul t c Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1)//. n ©O 0 Category 2) too J !41'M'Jb - ORO/.00 C2 Category 3) $ Total Contract Amount: $ If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state):'dqYI-91kIlnGw-vo Start/ End dates /G2r1v' _,'7_'3 O _ O �7 Owner: ��/Y%�%1�/i //• xg2'`h' o L1 ContactPerson: Telephone Number: ���_ Complete Mailing A dress: This project was managed by a: I Construction Manager O General Contractor D Architect/Designer N4check one) Name of Firm. lf"AA _"1T Contact Person: /v`� ^ (7l/l f 17 Telephone Number: /t Complete Mailing Addr-tsf 71 llyeq '�� e 20.Project Title: o Enter all appropriate Categorie(s) of Work (from page 9) and include a dollar breakdown for each category: Category 1) LD,/ Category 2) ����• Category 31 $� 0 C7 (,a Total Contract Amount: $ l 2,x'2, 00c? If applying for General Building Construction, Est the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ :r Project Location (city & state): �6j012- Start / End dates; j,27���- Owner:GJ/% vG 6®2 Contact PersonA Telephone Number: op6Q G V Complete Mailing Address- Jop olr'��esp. This project was managed by a: da? 0/ Construction Mana er D General Contractor D Architect/Designecheck one) Name of Finn: 1j��, !)110 ' f900,W 10/4 Contact Person: *A, /.�/Ghy! Telephone Number: CF O , g- 21 '031 Complete Mailing Address. Page 32 of 36 Prime/General Revised January 2009 Completed Projects (continued) 19.PrcjectTitle: f,Shc'�M JO f� ,c Enter all appropriate Categories) of'Work( from Page 9) and include a dollar breakdown for each category: _p Category 1) L� 7� Oc-� 4 Category 2) $ Category 3) $ Total Contract Amount: $ '—CF. t If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $. 3. $ Project Location (city & state): 410' An,, Start/ End dates: Owner: lv h Contact Person: % h -f'6-ee ;,,v, Telephone Number: -5 0do ?pp c, - Complete Complete Mailing Address: This project was managed by a: Construction Manager D General Contractor D Architect/Designer*check one) Name of Firm: C7 177n /'> ~ �T Contact Person: fcv /7,nn Telephone Number:J-0c?. Complete Mailing Address: Page 32 of 36 Prime/General Revised January 2009 /20.Project Title: Enter all appropriate Categories) of Work (from page 9) and include a dollar breakdown for each category: Category 1)Lv'�$ ��C� • a(�V Category 2) $ Category 3) $ Total Contract Amount: $ C90 U If applying for General Building Construction, list the three (3) largest building -related sub - trades you supervised or self -performed on this project and provide a dollar breakdown for each: 1. $ 2. $ 3. $ Project Location (city & state): Start/ End dates: eievo � Owner:% Ctiij.GlG , JT /4 �GLPG� Contact Person: �G IC , %�01"Jeh - 011�W' Telephone Number: ?7 - GVS Complete Mailing Address: &o This projet�Cwas'ma4 - W- 0/Lf Construction Manager D General Contractor D Architect/Designercheck one) Name of Firm: I e ad-'e'w47 X00 Ail Contact Person: G, Ra Telephone Number: �%�j 6S 3 Complete Mailing Address: �. ;Cei"cation (notarization req ed) The undersigned, / hereby certifies: (type name) That I am an owner or principal of (company name) and that all answers and all statements contained in the attached application (including Sections F and G) for certificate of eligibility are complete, true and correct. Providing false or misleading information or failure to provide all required information will be considered grounds for denial, decertification and/or debarment. I attest to the accuracy of all information contained in this application and verify that the information submitted is in fact complete, accurate and true, under oath. Signed and Sworn under the Pains and Penalties of Perjury. Dated at This -Aay of 20//. BY (signature): ): 7� 1 �0` Type name: zh / y / PW Title or position: ss. (county) (state) Before me, �1'� �� I , personally appeared and -- -- - notary public) known to me to be AO e Z/4 ased ( e of officer) on satisfactory evidence which was his/her driver's license and acknowledged that he/she is authorized to execute the foregoing and that its execution is his/her free act and deed and the free act and deed of the firm. 0/&� My commissilemf$Xp`. otary lic signore) Notary Public = My Commission Expires,iune 4, 201E z Commonwealth of k4a&sschusetts -- (print name) **Upon completion of this Application and the two corresponding Excel spreadsheets, save and email them to Cep-tificationApplication.deam(al.state.ma.us ** Page 16 of 16 Prime/General Revised March 2011 Computer