Company Name Contact Name First Last Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneFax NumberEmail Business Type Corporation Limited Liability Company Partneship Sole Proprietorship Established (mm/dd/yyyy): Month Day Year Federal Tax IDWA UBI Number:Licensed As: General Contractor Specialty Contractor Industry/Trade WA Contractor's Registration Number:Corporation, LLC, Partnership, or Proprietorship? Resident Agent (Corporation) Member (LLC) Principal (Partnership) Individual Owner (Proprietorship) Is the Resident Agent, Member, Principal, or Owner information different from above? Yes No Name First Last PhoneNumber of Years Providing Services?Total Employees Performing Service(s): Bonding Company: Bond Number:Bonding Limit:Insurance Company: Coverage Amount:Completed ProjectsList 3 projects you have completed within the past 5 years involving the type of work you wish to be prequalified for.Project 1Project Name / Location PhoneOwner Owner Representative Project Description Completion Date (mm/dd/yyyy) MM slash DD slash YYYY Total Price:Project 2Project Name / Location PhoneOwner Owner Representative Project Description Completion Date (mm/dd/yyyy) MM slash DD slash YYYY Total Price:Project 3Project Name / Location PhoneOwner Owner Representative Project Description Completion Date (mm/dd/yyyy) MM slash DD slash YYYY Total Price:Service PerformedGeneral Flagging / Traffic Control Janitorial / Building Maintenance Moving / Relocation Services Portable Toilet Services Pressure Washing Snow Removal Concrete and Masonry Concrete - Cutting / Coring / Drilling Concrete - Paving / Patching Masonry - Construction Earthwork Erosion Control Excavation and Trucking Grading Horizontal Boring / Drilling Structural Fill / Compaction Electrical Electrical - Construction Electrical - High Voltage Electrical - Low Volage Electrical - Meter Testing Lighting Pole Testing / Treatment Substation Construction Substation Maintenance Facilities / Site Improvements Building Construction Fencing / Gates Flooring HVAC Metal Fabrication / Welding / Machining Painting - Exterior & Interior Pest Control Plumbing - General Pumps - Maintenance and Repair Roofing Windows - Installation and Repair Woodwork Generators Fueling Installation / Maintenance / Repair Landscaping / Vegetation Management Landscaping / Landscape Maintenance Re-vegetation / Restoration / Hydroseeding Spraying / Herbicide Application Stump Grinding / Removal Tree Trimming / Removal Vegetation Control, Removal / Disposal Roadways Asphalt and Concrete —Paving Asphalt and Concrete —Cutting / Grinding Structures Portable Offices Portable Storage Containers Prefabricated Metal Buildings Wood Frame Buildings Wood Pole Buildings Water Facilities Backflow—Installation / Repair / Testing Fire Hydrant—Installation / Repair Hot Tapping Leak detection Meters—Industrial / Commercial Pump—Installation / Inspection Pump—Maintenance / Repair Reservoir—Cleaning / Caulking Reservoir—Construction Reservoir—Painting (interior/exterior) Well—Drilling Water main—Construction / Repair Other Other Certification of Compliance with Wage Payment StatusConsent The bidder hereby certifies that, within the 3-year period immediately preceding the bid solicitation date, the bidder is not a ‘willful’ violator, as defined in RCW 49.48.082, of any provision of chapters 49.46, 49.48 or 49.52 RCW, as determined by a final and binding citation and notice of assessment issued by the Department of Labor and Industries or through a civil judgment entered by a court of limited or general jurisdiction. I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. *Bidder certifies the authorized official does have authority to sign. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signatureBusiness Name Authorized Official Electronic Signature State of Incorporation or, if not a corporation, State where business entity was formed: Check One: Sole Proprietorship Partnership Joint Venture Corporation If a co-partnership, give firm name under which business is transacted: Consent Skamania PUD conducts its small works projects pursuant to RCW 39.04.155. Applications must be mailed, emailed to ktennison@skamaniapud.com, or delivered to the PUD at the above address. Incomplete, faxed, or unsigned applications will not be accepted. The Contractor is required to pay prevailing wages in accordance with RCW 39.12 and RCW 54.04.090 (or Davis-Bacon and Related Acts, if applicable) and submit intent and affidavit forms to Skamania PUD accordingly. As a condition of payment, Contractor agrees to send its final invoice to Skamania PUD within 90 days of acceptance of their work by the PUD unless otherwise is agreed to in writing. To remain on the roster, a new application must be filed every three years. Applications expire three years from the date of receipt. Applicants are responsible for re-applying before expiration of their application to insure they are not removed from the roster. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signatureApplicant Electronic Signature (Full Name) NameThis field is for validation purposes and should be left unchanged.
