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Small Works Roster

CHIMACUM SCHOOL DISTRICT

“CREATING THE FUTURE TODAY”

P.O. BOX 278

CHIMACUM, WA  98325

Henry Florschutz, Director of  Maintenance

360-302-5982                       Fax: 360-732-4381

 

SMALL WORKS ROSTER APPLICATION

 

Company Name:________________________________________________________________

Address:_______________________________________________________________________

Business Phone:______________________ E-Mail Address:______________________________

Is your firm incorporated? Yes____  No____  Number of employees______________________

Name and title of person(s) authorized to sign quotations/bids:

 _____________________________________  _______________________________________

 

WA State Contractors License#________________________ Expiration date:_______________

Federal I.D. # or Social Security # ___________________________________________________

WA State Account Numbers:  Dept. Labor & Industries__________________________________

                                               Dept. Employment Security________________________________

                                               Dept. of Revenue________________________________________

Liability Coverage: Bodily Injury________________                       Property Damage_______________

Performance Bond:    Yes____          No____           Amount:_____________________________

Has your firm performed work for the Chimacum School District Yes_________  No__________

List work performed for three public agencies, description of work performed, date, phone # and a contact person:____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Prevailing wages: Applicant hereby agrees to pay prevailing wages, as determined by the State of WA Dept. of Labor and Industries, on all District projects.

Is your firm an Equal Opportunity and Affirmative Action Employer? Yes____   No_____

Service/projects your firm is equipped, experienced and qualified to perform:

 

Architect/engineer ___         Alterations ____  Boiler repair/cleaning ____    Building____

Cabinet work ____     Concrete ____  Drywall ____            Electrical____ Fencing ____ 

Insulation ____ Irrigation ___   Landscaping ____  Masonry ____     Mechanical ____

Painting ____ Paving____   Plumbing ____  Roofing ____ Sewer ____  Sheet Metal ____

 

         Signature______________________________________                         Date________________