prequalification SHORT-Form / TUTOR PERINI BUILDING CORP.
130 N. 18th Street, Suite 1500
Philadelphia, PA 19103
610-668-4100
/
DATE:
  1. Company Information:

Company Name: / Telephone:
Address: / Fax:
Contact: / Website:
  1. Is this Office the: ☐Main ☐Regional ☐Branch Office

Is this company a: ☐Corporation ☐Partnership ☐Individual ☐Joint Venture ☐Other

Provide a list of all company locations, an organizational chart, resumes of principals and MWDBE certifications if appropriate.

Scope(s) of WorkPerformed.

☐01000General Conditions☐12000Furnishings

☐03000Concrete☐13000Special Construction

☐04000Masonry☐14000Conveying Systems

☐05000Metals☐15000Mechanical

☐06000Wood and Plastics☐21000 Fire Suppression

☐07000Thermal & Moisture Protection☐22000Plumbing

☐08000Doors & Windows☐23000 HVAC

☐09000Finishes☐26000Electrical

☐10000Specialties☐31000Site Work

☐11000Equipment☐32000 Exterior Improvements

List specific CSI or work performed on the lines below:

3. Company License Information:

State / License No. / License Expiration / Monetary Limit of License
  1. List those individuals, as applies, involved within the company:

Title: / Telephone: / Email: / Notes:
Officer:
Officer:
Principal:
Safety Director:
Primary Contact:
  1. Signatory to the following labor agreements. Please provide renewal dates as well as a copy of the most recent certificate.

Union / Local # / Renewal Date
  1. How many years has your company been in business? ______(years)
  1. Has your firm ever failed to complete an awarded contract? ☐Yes ☐ No

If yes, please attach a paragraph stating why work was incomplete. Providelocation, type of work,

owner or owners’ rep, architect and contract amount.

  1. Do you qualify as a minority business enterprise? ☐Yes ☐ No

Do you qualify as a woman-owned enterprise? ☐Yes ☐ No

Do you qualify as a disadvantaged-owned enterprise?☐Yes ☐ No

Do you qualify as a small business enterprise? ☐Yes ☐ No

Do you qualify as a section 3business concern? ☐Yes ☐ No

IF YES, ATTACH CERTIFICATION LETTER AND ENCLOSE DATES

  1. Can you provide a payment and performance bond if required? ☐Yes ☐ No
  2. Attach a letter from Surety Company stating aggregate bonding capacity and single contract limit.

$ Single Contract Limit $ Bonding Capacity

Indicate size of your average contract:

☐ Up to $500,000 ☐$500,000 - $2,000,000 ☐ $2,000,000 – $5,000,000 ☐ $5,000,000+

  1. Present value of work under current contract(s): $______
  1. List or attach last four projects completed, their size, and type of work, date completed, location, contract value and owner’s name.

Completed last four projects

Job Name / Type / Location / Contract $ / Owner Contact / Owner Phone / Date Complete
  1. References: List at least three (3) for each type:

Suppliers:

Company / Address / Phone / Contact Name / Position

General Contractors:

Company / Address / Phone / Contact Name / Position

Architects:

Company / Address / Phone / Contact Name / Position
  1. List LEED projects and certifications achieved within the last 5 years.

Project Name: / Project Address:
LEED Certification Level:
Contact Name: / Contact Telephone:
Contact Email:
Project Name: / Project Address:
LEED Certification Level:
Contact Name: / Contact Telephone:
Contact Email:
Project Name: / Project Address:
LEED Certification Level:
Contact Name: / Contact Telephone:
Contact Email:
Project Name: / Project Address:
LEED Certification Level:
Contact Name: / Contact Telephone:
Contact Email:

Provide any awards/recognition for projects within the last 10 years.

Award / Recognition:
Description:

15. Safety

List your Company’s Workers’ Compensation Interstate/Intrastate Experience Modification Rate for the most recent three years. (Attach a copy of your insurance carrier or state fund (on their letterhead) verifying the EMR data.

Interstate (Yr. /Rate)

201__ /______201__ /______201__ / ______

OSHA violation(s)received in the last three years? (Yr. = # violations)

201__ =______201__ =______201__ = ______

Any employee deaths in the past 3 years? ☐Yes ☐ No

If yes, please give a brief description of the circumstances:

Do you have a qualified person responsible for safety within your Company? ☐Yes ☐ No

Does this person do safety inspections on all of your projects? Frequency ______☐Yes ☐ No

Do you have a written Company Safety Policy and Program? ☐Yes ☐ No

Have you ever implemented 100% fall protection? ☐Yes ☐ No

If requested can you provide a site-specific program addressing ☐Yes ☐ No

the fall hazards in your work?

Do you require documented safety meetings for your employees?

Field Supervisors: ☐Yes ☐ NoFrequency ______

New Hires: ☐Yes ☐ NoFrequency ______

Employees: ☐Yes ☐ NoFrequency ______

Subcontractors/Vendors:☐Yes ☐ NoFrequency ______

Does your Company provide safety training for all employees? ☐Yes ☐ No

If yes, please list training provided.

Does your Company set annual safety goals? ☐Yes ☐ No

If yes, please list training provided.

Does your Company have a program recognizing your employees for safety ☐Yes ☐ No

performance excellence?

Does your Company have a disciplinary program in place for safety violations? ☐Yes ☐ No

Does your Company review the safety management systems of your ☐Yes ☐ No

subcontractors?

Does your Company conduct accident/incident investigations? ☐Yes ☐ No

16. Subcontractor Insurance:

Agent/Broker:
Contact:
Phone:

17. If your firm does not prequalify as a prime contractor for specific packages would you like information about your company forwarded to the active bid list for sub tier opportunities?

Please include the correct contact information below.

Contact Name:
Phone:
Email:

PLEASE NOTE:

All of the above information must be completed. It is of particular importance that you attach copies of the documents requested. Without the complete scope of information requested, Tutor Perini Building Corp. may be unable to include your firm in the bid solicitation.

The Subcontractor shall provide additional information as follows:

  1. Resumes of principals or key personnel
  2. Prequalification M/W/DBE CUF Self-Affirmation (separate attachment)
  3. Organizational Chart
  4. Letters of recommendation, marketing materials, or any other information demonstrative of the contractors experience, skill, ability, and integrity.

The Subcontractor is required to inform TPBC of all work being contracted to any firm outside of those listed on this statement. All outside firms must be pre-qualified by TPBC prior to the award of work to ensure they meet the qualifications required.

Thank you for taking the time to complete this statement. We look forward to working with you in the near future.

We have attempted to answer all questions in a full and complete manner to assurethat our answers are not in any respect misleading either by expressing ourselves in a misleading or ambiguous manner or omitting information. We recognize that TPBC willbe relying on the accuracy of the information and our responses in this questionnairein deciding whether to permit us to bid and in awarding work to our Company.

Dated this ______day of ______, 2015.

Name of Company:______

Signature:______

Title:______

Tutor Perini Building Corp – Prequalification Short Form 2015-10-12 Page1 of 6