Certification
Contractor Responsibility
For
LowerMakefieldTownshipCommunityCenter
Project# 12-77-OIZC
La
F i r mN a m e :
gertl
FirmAddress:
C o n t a cN
t ame:
Q *tt "ltt
T e l e p h o nN
e o.:
F a xN o . :
E m a iA
l ddress:
The submittingfirm is required to certify compliancewith the contractor responsibility
submittingfirms must be ableto
standardsset forth belowby checkingappropriateboxes.Specifically,
'J,,2
and 9,I0, I'J,,L2, and 13 and answer"No" to Questions3
fegitimately
answer"Yes"to Questions
through8, in orderto be considered
for the awardof the contractfor this project.
M y"r (1)
f] ruo
required
registrations
or certificates
Doesthe firm haveall valid,effectivelicenses,
by federal, state, county, or local law, including, but not limited to, licenses,
locale;and (b)
registrations
or certificatesrequiredto: (a)do businessin the designated
performthe contractwork it seeksto perform,includingbut not be limitedto, licenses,
registrations
or certificates
for any type of trade work or specialtywork which the firm
proposesto self-perform?
T
I
V"s (21
for the contract,as requiredby applicable
Doesthe firm meet bondingrequirements
E
ruo
law or contractspecifications
and any insurancerequirements,
as requiredby applicable
law or contract specifications,including general liability insurance, workers
insuranceand unemployment
compensation
insurancerequirements?
Z VSt (3)
p/f,fo
/
Hasthe firm beendebarredby any federal,stateor localgovernmentagencyor
authorityin the pastthree (3)years?
(4)
Hasthe firm defaultedon any projectin the pastthree (3) years?
J7't"t
M ruo
(5)
Hasthe firm had any type of business,
contractingor trade license,registration,
or other
I
(6)
Hasthe tirm committeda willfulviolationof federalor statesafetylawsas determined
by a finaldecisionof a court or governmentagencyin the pastthree(3)years?
J /"t
Nf to
(7)
Hasthe firm or its ownersbeenconvictedof any crimerelatingto the contracting
|,Ft
Mruo
)rt
[f ruo
certification
suspended
or revokedin the pastthree (3)years?
business
by a final decisionof a courtor governmentagencyin the pastten (10)years?
cF-1
Hasthe firmwithinthe pastthree(3)years,beenfoundby a finaldecision
of a urtor
government
agencyin violationof any law applicable
to its contracting
including,
but not limitedto, licensing
laws,tax laws,promptpaymentlaws,
and
hour laws,prevailing
wage laws,environmental
lawsor others,wherethe
of such
violationwas the impositionof a fine, backpay damagesor any other type of
naltyin
the amountof S1,000.00
or more?
Doesthe firm agreeto payall craftemployees
that it employson the projectt
wageratesand benefitsas requiredunderthe Pennsylvania
Prevailing
WageAct
current
r the
durationof the referencedproject?
Doesthe firm haveall other technicalqualifications
and resources,
includingeq pment,
personneland financialresources,
to performthe referencedcontractor agree
obtainsamethroughthe useof qualified,responsible
subcontractors?
( 1 1 ) Doesthe firm agreeto notifythe Ownerof any materialchangesto any matters ttested
to in this certification
within the seven(7)days?
(1 2 ) Doesthe firm understandand agreethat , if it receives
a Noticeof Intentto
contract,it shallprovidethe owner withinseven(7) daysa subcontractor t h a t
identifiesany subcontractors
it will use in connection
with the projectand furnish
ContractorResponsibility
Certifications
for all identifiedsubcontractors
with all
supportingdocumentation.
uired
Doesthe firm understandand agreethat thiscertificationmust be executedby a
authorizedrepresentativeof the firm who has sufficientknowledgeto a
s all
matteraddressed
herein,and attests,underpenaltyof perjury,that all info
submitted
istrue,complete
andaccurate?
tion
cF-2
In executingthis Responsibility
Certification,the submittingfirm understandsand a
if LowerMakefieldTownshipdeterminesthat this certificationcontainsfalseor misleading
informationthat was providedknowinglyor with recklessdisregardfor the truth or omits
erial
disregard
informationknowinglyor with reckless
of the truth, the firm shallbe proh
from
performingwork for LowerMakefieldTownshipfor a periodof three (3) years. Suchci
shall also subject the firm to any other penaltiesand sanctions,includingcontract
that
erial
ances
ination,
availableto the Townshipunder law. A contractterminatedunder these circumstan shall
firm as
further entitle Lower MakefieldTownshipto withhold paymentof any moniesdue to
damages.
regardingthe past performance
I certify that the foregoingrepresentations
and
qualifications
firm aretrueandcorrect.
of the undersigned
UO.L
bcln"r
of Firm
Subscribed
andswornto
beforemethis
day
My Commission
Expires:b
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Contractor
Responsibility
Certification.Docx
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