HomeMy Public PortalAboutPrequalification NEW BIDDER Application for Construction 2020 updated 2-1-2021Page 1 of 39
2/1/2021
THE METROPOLITAN ST. LOUIS SEWER DISTRICT
2350 Market Street
St. Louis, MO 63103
Attn: Purchasing Department
Elizabeth Goetz (314) 768-6269
and
Stacey Hunter (314) 436-8738
CONSTRUCTION PRE-QUALIFICATION APPLICATION
For the Period of 7/1/2020 thru 6/30/2021
(USED IN PRE-QUALIFYING ALL NEW BIDDERS ON CAPITAL CONSTRUCTION WORK)
___________________________________________________________
SUBMITTED BY (COMPANY)
___________________________________________________________
ADDRESS
___________________________________________________________
CITY, STATE, ZIP CODE
___________________________________________________________
DATE
___________________________________________________________
CONTACT NAME (FOR QUESTIONS) - TELEPHONE & FAX
TAX ID NUMBER
_____________________________________________________________
E-MAIL ADDRESS FOR BID NOTICES
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PREQUALIFICATION CHECK LIST Below is a checklist of required documentation
Signed Conflict of Interest Statement (Page 5).
Boxes checked indicating type of work requested (Page 8).
Bonding capacity indicated (Page 9).
Equipment Sheet is complete (Page 28).
Affidavit is complete with Notary Seal for whichever type of business is applicable (35-39).
Attach Certificate from the Secretary of State (Certificate of Good Standing) showing company is authorized to transact business in the State of Missouri.
Attach ACCORD Certificate of Insurance with MSD as certificate holder (pages 29-34).
Attach drain layers license for City of St. Louis and/or St. Louis County (required for Sewer Construction and Deep Sewer Construction categories).
Demolition work for MSD within the City of St. Louis – attach certification for specific classification. o Class I – no building size restrictions. o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. o St. Louis County does not require license.
Supplier form (can be found here: https://msdprojectclear.org/doing-business/suppliers/ (Download “New Supplier Data Form”). Please submit this with your package if you are a new bidder or if you are an existing bidder and you have any changes to your contact information or company.
W-9
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RULES AND REGULATIONS FOR PREQUALIFICATION OF CONTRACTORS
ON WORK LET BY CONTRACT WITH
THE METROPOLITAN ST. LOUIS SEWER DISTRICT 1. An applicant for pre-qualification must furnish, under oath, detailed information with respect to its equipment, past record, personnel, and experience, together with other information as is called for in this Prequalification Application. 2. A contractor must be prequalified prior to bid opening of a project. 3. Any combination of qualified or unqualified contractors bidding jointly becomes a new contracting firm and it must be pre-qualified in accordance with these rules. All applications shall be in writing and signed by the principal parties in the joint venture. 4. Pre-qualification Application forms must be filed by July 1st of each year. This form must be completed in detail. The District may require any additional information deemed necessary for pre-qualification. Companies pre-qualified within 3 months prior to this date will not need to submit a renewal application until the following year. 5. No bidder will be pre-qualified unless its Pre-qualification Application indicates that it has the experience, organization, and equipment, sufficient in the judgment of the District, that it can satisfactorily execute its contracts and meet its obligations therein incurred. 6. The Financial Statement of the controlling individual or corporate owner of the business may be requested by MSD as part of the prequalification review. If requested by MSD the Financial Statement shall be submitted or the review cannot be completed. 7. If any significant change occurs in the information included on the contractors’ pre-qualification form, notice shall be given to the District immediately. 8. All corporations must furnish a certificate from the Secretary of State showing that it is authorized to transact business in the State of Missouri 9. A copy of your firm's Certificate of Insurance meeting the Districts coverages is required. 10. A copy of the applicable drain layers license from the City and/or County of St. Louis is required for Sewer Construction or Deep Sewer Construction. 11. Demolition work for MSD within the City of St. Louis – attach certification for specific classification. o Class I – no building size restrictions. o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. o St. Louis County does not require a license. NOTE: It is important that the work experience pages in Section V be completed and that it contains projects of the type for which pre-qualification is being requested. Pre-qualification will not be granted for types of work that you subcontract to others.
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IMPORTANT INFORMATION FOR PROSPECTIVE BIDDERS 1. CONTRACT DOCUMENTS Contract documents include, but may not be limited to; the advertisement, Instructions to Bidders, Proposal, General Specifications, Detailed Specifications, Agreement, Bond Form, and Plans. The documents are available on and after the day advertisement is published and will be available via MSD’s website at https://msdprojectclear.org/doing-business/capital-improvement-replacement-program/capital-construction/. Look for a link to “ELECTRONIC PLANROOM”. Plans and specifications are also available for viewing or purchase at Cross Rhodes Reprographics located at 2731 South Jefferson, St Louis, Missouri 63118. 2. PREQUALIFICATION A contractor must be pre-qualified prior to bids being opened. 3. SPECIAL PROVISIONS Any special provisions or requirements concerning the work on any particular contract will be noted in the contract documents or on the Plans. 4. MINIMUM WAGE AND EMPLOYMENT DISCRIMINATION The minimum wage to be paid to all labor will be shown in the contract documents where applicable. Prevailing rates of pay shall be paid to skilled and unskilled labor, and there shall be no discrimination in the selection or employment of labor on account of race, creed, or color. 5. BID SECURITY The bid shall be accompanied by a certified check or cashier's check drawn on a bank or trust company located in either St. Louis City or County or by a bid bond issued by a surety company satisfactory to the District and which is authorized to transact business in Missouri. 6. RIGHT TO REJECT The Metropolitan St. Louis Sewer District reserves the right to reject any and all bids and to waive technicalities.
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VENDOR’S CONFLICT OF INTEREST STATEMENT 1. Name the individual or company requesting to do business with The Metropolitan St. Louis Sewer District (MSD). 2. In the past two (2) years has the individual or company name in 1. above (or any principal of such company, i.e. partner, officer, director, etc.) contributed cash or gifts in excess of $200.00 in value in the aggregate in any calendar year to any of the individuals or organizations listed on Attachment A hereto? Yes No If yes, describe in detail (date/amount/description). 3. In the past two (2) years, has the individual or company named in 1. above done business with any person listed in Attachment and/or their respective companies. Yes No If yes, describe in detail (date/amount/description).
4. The undersigned certifies that the above information is true and correct to the best of his
or her knowledge and belief.
Dated this day of _________________. 20 _
Printed Name: _____
Title: _____
Company Name: _____
Signature: _____
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ATTACHMENT A
NOTE: Attachment A contains a list of the MSD Trustees and their respective employer, MSD
officers and Directors, and the organizations which each are individually associated with,
as applicable.
Updated September 21, 2020
MSD BOARD OF TRUSTEES & DIRECTORS
Trustee/Director Name of Firm, Organization or Company Affiliation
Bret A. Berthold American Water Works Association (AWWA) Member
Director Engineers Club of St. Louis Member
Missouri Water Environment Association Member
National Association of Clean Water Agencies (NACWA) Member
Water Environment Federation Member
Tracey Coleman Association for Talent Development Member
Director St. Elizabeth Mother of John the Baptist Member
Society for Human Resource Management Member
Michael Evans AFL-CIO Lawyers Coordinating Committee Member
Trustee Bar Association of Metropolitan St. Louis Member
Hartnett Reyes-Jones, LLC Partner
International Foundation of Employee Benefit Plans Member
Kentucky Bar Association Member
Missouri Bar Association Member
St. Louis City Labor Legislative Club Member
Amy L. Fehr Algonquin Golf Club Member
Trustee American Bar Association Member
Bar Association of Metropolitan St. Louis Member
Capes, Sokol, Goodman and Sarachan, PC Shareholder & Director
Federal Bar Association, St. Louis Chapter Member
Missouri Bar Association Member
Marion M. Gee American Water Works Association (AWWA) Member
Director Church on The Rock Member
Government Finance Officers Association (GFOA) Executive Board
Missouri Government Finance Officers Association Member
Brian Hoelscher Engineers Club of St. Louis Member
Executive Director Missouri Water Environment Association Member
National Association of Cleanwater Agencies (NACWA) Executive Board
Project MOSAIC Ambassador/Connector
Washington University in St. Louis - W Club Executive Council
Water Environment Federation Member
Susan M. Myers Association of Corporate Counsel Member
Director Association of Missouri Cleanwater Agencies (AMCA) Board Member
Bar Association of Metropolitan St. Louis Member
Missouri Bar Association Member
National Association of Cleanwater Agencies (NACWA) Member
Betsy Schubert Institute for Supply Management Member
Manager
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Updated September 21, 2020
MSD BOARD OF TRUSTEES & DIRECTORS
Trustee/Director Name of Firm, Organization or Company Affiliation
James I. Singer AFL-CIO Lawyers Coordinating Committee Member
Trustee American Bar Association Member
American College of Employee Benefit Counsel Member
Bar Association of Metropolitan St. Louis Member
Electricians Historical Society Board member
Illinois Bar Association Member
Missouri Bar Association Member
Missouri Botanical Gardens Member
Missouri Historical Society Member
Schuchat, Cook and Werner Partner
Shaare Emeth Congregation Member
St. Louis University Law School Adjunct Faculty
St. Louis Zoo Member
Timothy R. Snoke
Director Contractor Loan Fund Board Member,
Executive Committee
Government Finance Officers Association Member
Institute of Management Accountants Member
Jonathon Sprague
St. John's Lutheran Church Member
Director Member
Missouri Water Environment Member
National Association of Clean Water Agencies (NACWA) Member
Water Environment Federation Member
Rich L. Unverferth Engineers Club of St. Louis Member
Director Knights of Columbus - Council 2119 Webster Groves Member
National Association of Clean Water Agencies (NACWA) Member
St. Michael the Archangel Catholic Parish Member
Ret. Col. Richard R.
Wilson
American Institute of Parliamentarians
Member
Trustee Anniversary Club Member
Oaks Social Club Treasurer
Pathfinders Golf Club Treasurer
Pin High Golf Club Member
Reserve Officers Association Member
Royal Vagabonds Foundation, Inc. Board Member
Royal Vagabonds, Inc. Member
Michael E. Yates
North County Labor Legislative Club
Executive Board
Member
Trustee St. Louis Labor Council Delegate
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APPLICATION FOR CERTIFICATE OF QUALIFICATION TO BID The undersigned hereby applies to the Metropolitan St. Louis Sewer District for a Certificate of Qualification to bid the following types of work: (Check each type of work for which qualification is requested) ________ Sewer Construction
Section V. A., Page 12. Drain layers license required for City or County.
________ Deep Sewer Construction
Section V. B., Page 14. Drain layers license required for City or County. To qualify in this category
a contractor must demonstrate experience on multiple projects that are deemed complex by the
District. Typically a project would be considered complex when the installation of the pipe required
excavation at depths greater than 20 feet for an extended length along with one or more of the
following addition construction challenges: significant involvement with trench bracing for urban
type features; significant amounts of Class “A” or Class “B” excavation; significant amount of poor
soil conditions; significant length of large diameter pipe installation (36-inch or larger); or installation
in locations having extremely limited working room. The District shall be the sole judge as to
whether a project is considered complex.
________ Building Construction
Section V. C., Page 16
________ Natural Channel Stabilization
Section V. D., Page 17
________ Green Infrastructure and Bio-Retention
Section V. E., Page 18
________ Pipe and Manhole Rehabilitation
Section V. F., Page 19
Cured-In-Place Pipe (CIPP)
Section V. G, Page 20 - 21
Cured-In-Place Lateral Liner (CIPL)
Section V. H, Page 22 & 23
________ Concrete Channels, Walls and Structures
Section V. I., Page 24
________ Mechanical/Electrical/Plumbing
Section V. J., Page 25
________ Tunneling / Trenchless
Section V. K., Page 26
________ Demolition
Section V. L., Page 27; and for explanation of Class I & II ________ St. Louis County Demolition ________ St. Louis City – Class I and II ________ St. Louis City – Class II only
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TYPE OF ORGANIZATION (Check Applicable Category)
_____ Corporation ______ Partnership ______ Joint Venture ______ Individual _________LLC
Firm Name: ________________________________Firm Address: ________________________
By ___________________________________ Title _________________________
_________________________________
(Signature) THE SIGNATORY OF THIS APPLICATION GUARANTEES THE TRUTH AND ACCURACY OF ALL STATEMENTS AND OF ALL ANSWERS TO INTERROGATORIES HEREINAFTER MADE Please list any previous experience or projects your company has completed for each category you are requesting approval for, and any references you can provide. Attach additional sheets if necessary. Name of Contractor _____________________________________________________ Principal Address _______________________________________________________ ( ) A corporation ( ) A partnership ( ) A joint venture ( ) An individual ( ) A limited liability corporation ( ) MWBE (Minority or Woman Business Enterprise) If MWBE, what is the name of the agency/organization that issued the certification document? _______________________________________________________________ Please attach a copy of your certification document to this application. Incorporated or organized: Date _______________________ State ______________________________________ Radius of operations: ______________________________________________________ Type of work done: ______________________________________________________ Work usually sublet: Name of Bonding Company _______________________________________________ Total Bonding Capacity of Firm $__________________________________________ I. How many years have you operated under the above name: (a) As general contractor _____________________________________________ (b) As subcontractor ______________________________________________
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II. List other names under which you have operated: Name of company _____________________________________________ Type of work done ______________________________________________ Operated during period ______________________________________________ Name of company ______________________________________________ Type of work done ______________________________________________ Operated during period _____________________________________________ III. List of all partners or officers: (Note: if partnership limited, explain and please list full 100% ownership) Name and title_________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned______________________ Name and title____________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned ______________________ Name and title ___________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned ______________________ IV. What is the construction experience of the principal individuals of your organization? (This includes the job superintendent). An individual’s name Present position or office Years of construction experience Magnitude and type of work An individual’s name Present position or office Years of construction experience Magnitude and type of work
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An individual’s name Present position or office Years of construction experience Magnitude and type of work
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V. Only list projects completed or in progress within the last five years in the categories for which you want to qualify. Attach additional sheets if necessary. SECTION A. - Sewer Construction (See definition on page 8) (Includes storm sewer, sanitary sewers, and small pump stations) 1. Contract Amount __________________ When Completed or Percent Complete__________________ Project Description/Scope of Work: ____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount _________________ When Completed or Percent Complete __________________ Project Description/Scope of Work: ____________________________________________ Pipe size and length laid______________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner__________________________________________ 3. Contract Amount __________________ When Completed or Percent Complete __________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid______________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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4. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 5. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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SECTION B. - Deep Sewer Construction (See definition Page 8) (Includes sanitary sewer, storm sewer, and small pump stations) 1. Contract Amount ____________________________________________________________ When Completed or Percent Complete____________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid___________________________________________ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ___________________________________________________________ When Completed or Percent Complete _______________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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4. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 5. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION C - Building Construction (Includes large pump stations, treatment plants, and operational facilities) 1. Contract Amount ___________________________________________________________ When Completed or Percent Complete___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project __________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone Number of Owner _______________________________________ 2. Contract Amount __________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: ____________________________________________ Location of Project__________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount __________________ When Completed or Percent Complete __________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner____________________________________________ 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION D. Natural Channel Stabilization: 1. Contract Amount _____________ When Completed or Percent Complete Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project ________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner _____________________________________________ 2. Contract Amount _____________When Completed or Percent Complete _______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ___________________________________ Location of Project___________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of __________________________________________________ 3. Contract Amount ______________When Completed or Percent Complete ______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ______________________________ Location of Project___________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner 4. Contract Amount ______________When Completed or Percent Complete ______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION E. Green Infrastructure and Bio-Retention 1. Contract Amount ____________When Completed or Percent Complete Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project ________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner ____________________________________________ 2. Contract Amount _______________When Completed or Percent Complete _____________ Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount _______________ When Completed or Percent Complete _____________ Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner ________ __________ 4. Contract Amount _______________When Completed or Percent Complete _____________ Project Description/Scope of Work: ____________________________________________ Specify green infrastructure methods installed______________________________ Location of Project___________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION F. - Pipe and Manhole Rehabilitation (Give pipe sizes) (Includes point repair, pipe bursting, slip lining, etc.) 1. Project name, scope and description:___________________________________________ Contract Amount __________________________________________________________ When Completed or Percent Complete ________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Project name, scope and description:___________________________________________ Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Project name, scope and description:____________________________________________ Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner 4. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION G. – Cured-in-Place Pipe (CIPP) Statement of Qualifications for Cured-in-Place Pipe 1. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________
Manufacturer of CIPP product ___________ Trade Name of CIPP product ______________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
__________________________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Installed Pipe Length: _____ Pipe Sizes: _____
Pipe Type: Gravity ____ Pressure _______
Project Owner: ______________________________________________________________
Contact Name: ___________________________Contact No.:________________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus ___________________________
Tensile Strength _____________ (only applicable for pressure pipe)
2. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________
Manufacturer of CIPP product ___________ Trade Name of CIPP product ______________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
___________________________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______ Pressure _______
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Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION H. – Cured in Place Lateral Lining (CIPL) Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral connection repairs). 1. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________
Manufacturer of CIPL product ___________ Trade Name of CIPL product _________________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: _____________________
Manufacturer of Water Tight Seal (waterstop): _____________________________________
Manufacturer of Lateral Connection Repair (LCR): _________________________________
(Attach written documentation from manufacturer certifying that contractor is an
approved installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________ Flexural Modulus __________________
2. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________
If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin)
_________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
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Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an
approved installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________ Flexural Modulus __________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION I. - Concrete Channels, Walls & Structures 1. Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project ________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: ____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION J. - Mechanical/Electrical/Plumbing 1. Contract Amount ______________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION K. – Tunneling / Trenchless 1. Contract Amount ______________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project ________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: ____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION L. – Demolition Demolition work for MSD within the City of St. Louis – attach certification for specific classification. Class I–no building size restrictions. Class II -limited to buildings under 3 stories / 50 feet high / 50,000 square feet area / 200,000 cubic feet volume. Buildings under 1 ½ stories / 10,000 cubic feet volume, with no basement, require no demolition license. St. Louis County – does not require license. 1. Contract Amount ______________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project ________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________
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EQUIPMENT (What equipment do you own that is available for proposed work?) QUANTITY ITEM DESCRIPTION, SIZE, CAPACITY, ETC
EQUIP HOURS
CONDITION YEARS OF SERVICE
PRESENT LOCATION
* Condition shall be graded as follows: New under 12 months Over 12 months old Rebuilt N-1 0-1 (Good) R-1 0-2 (Average) R-2 0-3 (Fair) R-3 0-4 (Poor) R-4 (Poor)
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SAMPLE INSURANCE REQUIREMENTS REVISED 7/19/17:
The following section supplements the provisions of Part 1, Section F, paragraph 8 of the
Standard Construction Specifications (2009).
a. Within fifteen (15) days after written notification by the District that the bid proposal has
been accepted and receipt of the contract for signature, the Contractor must provide two
(2) copies of executed Certificates of Insurance on the ISO ACORD 25 Form or current
equivalent with the District, indicating that the bidder has obtained and will continue to
carry commercial general liability, comprehensive business auto liability, workers
compensation/employers’ liability, excess (umbrella), professional liability and pollution
liability as required. The initial and renewal Certificates of Insurance must identify the
MSD Project and Contract by name and reference number. A sample Certificate of
Insurance Form in the format required is attached to these specifications.
b. The Contractor shall carry and maintain adequate liability insurance as required by this
Contract with a company or companies satisfactory to the District and which are:
Licensed to do business in the State of Missouri (Admitted) with a financial strength
rating of “A-” or better and a financial size category of Class VI or higher per AM Best
Company; or
Not licensed in the State of Missouri (Non-admitted) with a financial strength rating of
“A” or better and a financial size category of Class IX or higher per AM Best Company;
or
For workers compensation coverage only, organized pursuant to the Missouri
Insurance Company Act (R.S.Mo §§ 287.900 to 287.920).
The insurance policy/policies will be acceptable regardless of the above requirements if
the insurance company furnishes a bond guarantee or policy containing a provision
(commonly referred to as a “cut-through” endorsement) giving all claimants thereunder a
direct right of recovery against the company’s reinsurer, provided the reinsurer meets one
of the qualifications listed above.
c. The amounts of coverage required herein shall not be construed to limit the liability of the
Contractor under the indemnification provision of the contract.
d. The District (including its Trustees, directors, officers, agents and employees), the
Consultant ___________________________, and the following Sub-consultants
_____________________________, shall be named as “Additional Insured(s)” for all
required insurance coverage (with the exception of pollution liability, professional liability
and workers compensation coverage) with respect to the
__________________________________ (state project). The Contractor shall require that
its sub-contractors name the District and the Contractor as “Additional Insured(s)”. The
additional insured coverage must be sufficiently broad to afford the District coverage as
required by the indemnification provision of the Contract and must include products and
completed operations coverage included within the commercial general liability policy.
e. In the event the Contractor is a joint venture, the following additional requirements shall
apply:
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1. If the joint venture secures separate stand-alone coverage in the name of the joint
venture for one or more of the required lines of coverage, each of the requirements set forth
below shall apply to that coverage and the certificate of insurance shall so indicate. The
District may request copies of the endorsements &/or policies of insurance to verify that
coverage is in the name of the joint venture.
2. If separate stand-alone coverage in the name of the joint venture is not provided for
one or more of the required lines of coverage, then for each such line of required coverage,
the following requirements shall apply: (i) the coverages of each of the joint venture
members must provide specific endorsements to each such line of required coverage; (ii)
The joint venture shall be endorsed to each such line of coverage; (iii) The joint venture
and each member of the joint venture must be “named insureds” for each such line of
coverage; and (iv) The certificates of insurance for each such joint venture member shall
be provided and shall reflect compliance with these requirements. It is anticipated that
business auto and workers compensation/employers’ liability coverage will not be secured
in the name of the joint venture, and will fall in this category.
f. The coverage and minimum limits of liability shall be in accordance with the specifications
below except as may be specifically modified elsewhere in the Contract Documents:
COMMERCIAL GENERAL LIABILITY
$1,000,000 Each Occurrence
$1,000,000 Aggregate/Per Project*
*The aggregate limits must be provided on a per project basis. Aggregate limits not provided on a
per project basis must be noted on the Certificate of Insurance and the District must approve in
advance.
The Commercial General Liability (CGL) policy shall include the following:
1. Premises – Operations Liability
2. Blanket Contractual Liability
3. Products & Ongoing and Completed Operations Liability
4. Contractor’s Protective Liability (Independent Contractors)
5. Personal Injury Liability
6. Broad Form Property Damage Liability Endorsement
7. Coverage for explosion, collapse and underground hazards (XCU)
8. Blasting (provided that blasting coverage may be excluded if not to be performed in
connection with the work)
If any exceptions or exclusions have been made to the standard CGL Policy, the exceptions and
exclusions must be specifically listed and identified in the Description of Operations section of the
Certificate of Insurance and must be submitted to the District for approval.
If using a non-standard policy form (Form CG 00 01 04 13 or equivalent), then additional
endorsements may be required.
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The commercial general liability policy must provide primary and non-contributory coverage that
is equivalent to the terms of ISO Form CG 20 01 04 13, Primary and Noncontributory Other
Insurance Conditions (or current equivalent).
The commercial general liability coverage including products and completed operations shall be
maintained for a minimum period of five (5) years following final payment.
BUSINESS AUTOMOBILE LIABILITY
$1,000,000 Combined Single Limit
Insurance shall apply to all owned, non-owned and hired vehicles. A MCS-90 endorsement shall
be included on the Policy when required by Missouri law.
WORKERS COMPENSATION & EMPLOYERS’ LIABILITY INSURANCE
Workers Compensation:
Statutory Limits
Workers Compensation Insurance shall comply with all applicable State and Federal laws,
including but not limited to U.S. Longshore & Harbor Workers (USL&H) Act and Jones Act.
Employers’ Liability:
$500,000 Each Accident
$500,000 Disease Each Employee
$500,000 Disease Policy Limit
EXCESS (UMBRELLA) COVERAGE – Applies to CGL, Business Auto & Employers
Liability
Excess coverage must be provided and with the following limits for each of the Commercial
General Liability, Business Auto & Employers’ Liability coverages. These limits are in addition
to the primary limits set forth above.
Limits For Contracts $100,000 & Over:
$5,000,000 Per Occurrence
$5,000,000 Aggregate
Limits For Contracts Less Than $100,000:
$2,000,000 Per Occurrence
$2,000,000 Aggregate
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POLLUTION LIABILITY
For contracts in excess of $100,000, the Contractor shall maintain in force for the full period of
the Contract, pollution liability insurance coverage in the minimum amount set forth below for
losses caused by sudden and non-sudden pollution conditions that arise from the operations of the
Contractor. Such insurance shall apply to bodily injury and property damage, including loss of
use of the damaged property or property that has not been physically injured, and shall cover
cleanup, transportation, disposal, remediation and defense costs, including all expenses incurred
in the investigation, defense, payment or settlement of claims.
$2,000,000 Per Claim or Occurrence
$2,000,000 Aggregate
If claims made, the insurance coverage shall be retroactive to the earlier of the date of this Contract
or the commencement of the Contractor’s work on the Project, and Contractor shall cause the same
to remain in effect for a period of at least five (5) years after final acceptance of the Project by the
District or such other period as may be set forth in the Contract or in the Project Specifications.
NOTE: For contracts less than $100,000, the District does not require the Contractor to provide
pollution liability coverage for the District. The Contractor may wish to provide such coverage for
its own protection. The District is not providing such coverage to the Contractor.
PROFESSIONAL LIABILITY
For contracts in excess of $5,000,000, Contractor shall maintain, or shall cause its subcontractor(s) providing professional design or advice to maintain, in force for the duration of this Contract errors
and omissions/professional liability insurance. Coverage as required in this Article shall apply to
liability for professional errors, acts or omissions arising out of the scope of the Contractor’s
services as set forth in this Contract and the Project Specifications.
$2,000,000 Per Claim or Occurrence
$2,000,000 Aggregate
If claims made, the insurance coverage shall be retroactive to the earlier of the date of this Contract or the commencement of the Contractor’s work on the Project, and Contractor shall cause the same
to remain in effect for a period of at least five (5) years after final acceptance of the Project by the
District or such other period as may be set forth in the Contract or in the Project Specifications.
NOTE: If Contractor provides combined Pollution Liability and Professional Liability coverage,
separate limits in the amounts required must be provided. If a policy aggregate applies, the
certificate of insurance must so indicate and the amount must be approved by the District.
DEDUCTIBLE/SELF-INSURED RETENTION:
For any coverage, a deductible or retention that exceeds $100,000 shall be noted and approved by
the District’s Risk Management Group. The District will reserve the right to review the funding
for a deductible or retention program. Satisfaction of any such deductible or retention shall be the
sole responsibility of the Contractor. If self-insured, the District reserves the right to request
acceptable proof of financial responsibility before approval.
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CANCELLATION:
Should any of the required insurance coverage be cancelled prior to the expiration date, the
Contractor must provide at least sixty (60) days written notice to the District prior to the
cancellation. For policy cancellation for non-payment of premium by the Contractor, the
Contractor must notify the District at least ten (10) calendar days prior to the cancellation.
Cancellation provisions within any coverage shall be in accordance with Missouri Cancellation and
Non-Renewal provisions. It is the duty of the Contractor to notify the District of any cancellation or
non-renewal and provide the District 60 days’ notice.
REPLACEMENT POLICY:
Should any of the required insurance coverage be cancelled, terminated or materially altered, the
Contractor will send written notice to MSD at least sixty (60) days prior to the effective date of
said cancellation, termination or alteration. Upon receipt of any notice of insurance cancellation,
termination or alteration, the Contractor shall within thirty (30) days procure other policies of
insurance identical in all respects to the policy or policies about to be canceled, terminated or
altered and shall provide the District with evidence of coverage before the cancellation or
termination date; and if the Contractor fails to provide, procure and deliver acceptable policies of
insurance and satisfactory certificates or other evidence thereof, the District may obtain such
insurance at the cost and expense of the Contractor without notice to the Contractor, and elect to
pursue any other remedy permitted by law or the contract terms, including but not limited to
termination of the Contract.
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Metropolitan St. Louis
Sewer District
2350 Market Street
St. Louis, Missouri 63103
RE: Insurance Requirements for Annual Pre-Qualification
Metropolitan St Louis Sewer District (MSD) requires contractors to be prequalified prior to
bidding on Capital Improvement Projects. In the prequalification process, contractors must
demonstrate their ability to perform in the event they are awarded a contract, including meeting
the District’s insurance requirements.
MSD has certain contract requirements relating to contractor insurance coverage, including
increasing the limits for certain coverage and requiring pollution liability coverage. The District
recognizes that these additional coverage requirements impose additional costs upon contractors.
In an effort to alleviate any short term burden on contractors, for pre-qualification and bid purposes
only, MSD is willing to accept a letter signed by both the contractor and the contractor’s insurance
broker stating that the contractor has been approved for the additional insurance coverage and that
the contractor will obtain all required coverage and with the limits required in the event a contract
is awarded to the contractor. Further, the letter must state affirmatively that the policy will be
endorsed and coverage will be in place in the event a contract is awarded. Additionally, the letter
must state that in the event a contract is awarded and insurance is not secured within the required
timeframe, the contractor will forfeit its bid bond on the project and will be determined non-
responsive. These affirmative representations must be repeated as part of any bid submitted by a
contractor that does not have the required coverage in place at the time of the bid.
Thank you for your cooperation in this matter.
Sincerely,
Betsy Schubert
Purchasing Manager
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AFFIDAVIT FOR CORPORATION
STATE OF _____________ )
) ss
COUNTY/CITY OF ___________ )
AFFIDAVIT
I, ____________________, depose and state as follows:
1. I am the _________________(title) of _____________________________________;
2. I am authorized to sign this Affidavit on behalf of the corporation;
3. The foregoing information and responses to interrogatories set forth herein are true and
correct to the best of my knowledge, information and belief; and
4. Any depository, vendor, agency or entity herein named is authorized to supply The
Metropolitan St. Louis Sewer District with any information appropriate to verify the
accuracy of any statement herein.
In witness hereof I have hereunto subscribed my name and affixed the official seal of the
corporation this day of ____, 20 .
Affiant
(Seal)
Subscribed and sworn to before me, a Notary Public, this day of
, 20___.
Notary Public
My commission expires:
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AFFIDAVIT FOR PARTNERSHIP
STATE OF _____________ )
) ss
COUNTY/CITY OF ___________ )
AFFIDAVIT
I, ____________________, depose and state as follows:
1. I am a partner in the partnership known as
____________________________________________________________;
2. I am authorized to sign this Affidavit on behalf of the partnership;
3. The foregoing information and responses to interrogatories set forth herein are true and
correct to the best of my knowledge, information and belief; and
4. Any depository, vendor, agency or entity herein named is authorized to supply The
Metropolitan St. Louis Sewer District with any information appropriate to verify the
accuracy of any statement herein.
In witness hereof I have hereunto subscribed my name this __ day of
________________, 20 .
Affiant
(Seal)
Subscribed and sworn to before me, a Notary Public, this day of
, 20___.
Notary Public
My commission expires:
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AFFIDAVIT FOR JOINT VENTURE
STATE OF _____________ )
) ss
COUNTY/CITY OF ___________ )
AFFIDAVIT
I, ____________________, depose and state as follows:
1. I am a joint venture partner &/or am authorized to sign this Affidavit on behalf of the
Joint Venture between _______________________ and _________________________;
2. The foregoing information and responses to interrogatories set forth herein are true and
correct to the best of my knowledge, information and belief; and
3. Any depository, vendor, agency or entity herein named is authorized to supply The
Metropolitan St. Louis Sewer District with any information appropriate to verify the
accuracy of any statement herein.
In witness hereof I have hereunto subscribed my name this __ day of
________________, 20 .
Affiant
(Seal)
Subscribed and sworn to before me, a Notary Public, this day of
, 20___.
Notary Public
My commission expires:
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AFFIDAVIT FOR INDIVIDUAL
STATE OF _____________ )
) ss
COUNTY/CITY OF ___________ )
AFFIDAVIT
I, _____________________________________, depose and state under oath that the foregoing
information and responses to interrogatories set forth herein are true and correct to the best of my
knowledge, information and belief. Any depository, vendor, agency or entity herein named is
authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate
to verify the accuracy of any statement herein.
In witness hereof I have hereunto subscribed my name and affixed my official seal this
day of ____, 20 .
Affiant
(Seal)
Subscribed and sworn to before me, a Notary Public, this day of
, 20__.
Notary Public
My commission expires:
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AFFIDAVIT FOR LIMITED LIABILTY COMPANY
STATE OF _____________ )
) ss
COUNTY/CITY OF ___________ )
AFFIDAVIT
I, ____________________, depose and state as follows:
1. I am the _________________(title) of _____________________________________, a
limited liability company;
2. I am authorized to sign this Affidavit on behalf of the limited liability company;
3. The foregoing information and responses to interrogatories set forth herein are true and
correct to the best of my knowledge, information and belief; and
4. Any depository, vendor, agency or entity herein named is authorized to supply The
Metropolitan St. Louis Sewer District with any information appropriate to verify the
accuracy of any statement herein.
In witness hereof I have hereunto subscribed my name on this day of
____, 20 .
Affiant
(Seal)
Subscribed and sworn to before me, a Notary Public, this day of
, 20___.
Notary Public
My commission expires: