Shiawassee County Housing Rehabilitation Program

CONTRACTOR APPLICATION FORM

This form must be completed for each contractor that intends to bid work that is assisted with Community Development Block Grant funds. Completion of this form puts you, as a contractor, on the list of "Available Contractors" that our staff will distribute to program participants. Copies of all current State of Michigan Contractor’s License(s) must be attached.

Contractors may be removed from the list for any of the following reasons:

    1. Poor workmanship
    2. Failure to meet project deadlines
    3. Failure to follow program specifications and requirements
    4. Poor evaluations from three or more clients
  1. GENERAL INFORMATION

Name of Company:

Street/Mailing Address:________________________________

City:___________________State:___ Zip Code:___________

Office Phone:(___)___________Office Hours:________________

Firm Owner:_______________________________________Federal EIN/Soc. Sec #:_______________________

Name of Person(s) Writing Bids:______________________________

Are you a General Contractor? Yes No When was your firm established?_______________

In which cities and/or townships are you willing to work? __________________________________________

How many contractors are part of your firm (other than subcontractors)?___________________

Can you handle more than one $5,000 job at a time? Yes_____ No_____

Do you carry Worker’s Compensation insurance? Yes _____ No _____

NOTE: Self-employed workers and Partnerships may be exempt.

Will you guarantee your work for two years? Yes _____ No _____

Is your business minority owned (more than 50%)? Yes _____ No _____

Is your business female owned (more that 50%)? Yes _____ No _____

Minimum requirements include commercial liability insurance and commercial auto insurance (if you have a vehicle owned by the company). When you are awarded a contract by a homeowner, you will be asked to list Shiawassee County Housing Rehabilitation Program as an additional insured and provide proof of insurance. The proof of insurance MUST be on file in the Program Office prior to beginning work.

II. AREAS OF EXPERTISE

Please check the type of work you are qualified to do and indicate the years of experience you have in that area:

Type of Work: Years of Experience:

__ General Carpentry ____________________

__ Roofing ____________________

__ Structural Support Repair ____________________

__ Window & Door Replacement ____________________

__ Siding ____________________

__ Masonry Installation & Repair ____________________

__ Plumbing ____________________

__ Electrical ____________________

__ Mechanical & Ventilation ____________________

__ Insulation & Weatherization ____________________

__ Kitchen Cabinet Installation ____________________

__ Floor Covering Installation ____________________

III. REFERENCES

List your top five major suppliers (name & phone #), starting with the largest volume credit account:

1.___________________________________________

2.___________________________________________

3.___________________________________________

4.___________________________________________

5.___________________________________________

List three recent jobs completed in the past three months (name, address & phone):

NAME, ADDRESS, PHONE

_______________________________ ______________________________ _______________

____________________________________________________________________________

____________________________________________________________________________

I authorize the CDBG Program Administrator to verify the above information and I certify that the above information is true and correct.

 

__________________________________________________ _________________

Signature, Date

ATTACH CURRENT MICHIGAN LICENSE(S) TO THIS FORM AND RETURN TO:

Attn: Linda Schonberg

Housing Rehabilitation Program

Surbeck Building, Third Floor

201 North Shiawassee Street

Corunna, MI 48817

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