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October 1, 1995 (Rev. 2/14/03) -1- PEFQUAL-1
North Carolina Department of Transportation Private Consulting Firm Qualifications Package
NAME OF FIRM
DATE
STATE
YEAR ESTABLISHED
CORPORATE ADDRESS A/C & TEL. NO. Physical Address: Mailing Address: ( ) FAX NO. ( ) NORTH CAROLINA BRANCH OFFICE(S) A/C & TEL. NO. Physical Address: Mailing Address: ( ) FAX NO. ( ) CONTACT PERSON Corporate: NC Branch: A/C & TEL NO. FAX NO. A/C & TEL NO. FAX NO. ( ) ( ) ( ) ( ) e-mail address: e-mail address:
This application is based on the following factors: (Check appropriate designation) CERTIFIED TOTAL EMPLOYEES ORGANIZATION TYPE OF APPLICATION DBE IN NC IN FIRM Individual ¨ New ¨ Yes ̈ Total Employees in Firm Partnership ¨ Updated ¨ No ¨ Total Employees in Corporation ¨ Reinstatement ¨ (If yes, attach a copy NC Offices of NCDOT certification letter) Total PE’s in NC Offices FEDERAL TAX IDENTIFICATION NUMBER Total LG’s in NC Offices Total PLS’s in NC DATE OF REGISTRATION AND REGISTRATION NUMBER WITH Offices SECRETARY OF STATE’S OFFICE DATE NUMBER (if applicable)
FIRM REGISTERED WITH NC STATE BOARD OF REGISTRATION FOR PROFESSIONAL ENGINEERS AND LAND SURVEYORS Yes ¨ License Number No ¨ (If yes, attach copy of latest certificate or renewal letter from Board) FIRM REGISTERED WITH NORTH CAROLINA BOARD FOR LICENSING OF GEOLOGISTS Yes ¨ License Number No ¨ (If yes, attach copy of latest certificate or renewal card from Board) I certify the information contained within this application is accurate. Submission of false information is cause for denial of prequalification with the North Carolina Department of Transportation. NAME OF FIRM OR INDIVIDUAL SUBMITTING APPLICATION NAME AND TITLE OF PERSON SIGNING: Signature Date
* This form can also be found at our web site: www.doh.dot.state.nc.us/guidelines (Click on Consultant Specific…PEF Qualifications - Prequalifications Form)
October 1, 1995 (Rev. 2/14/03) -2- PEFQUAL-1
CORPORATE HEADQUARTERS Highway Design Branch NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental
Draftsmen/CADD Soils Engineers Engineers
Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental
Draftsmen/CADD Soils Engineers Engineers
Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send a sample of work for each new area marked. ROADWAY DESIGN GEOTECHNICAL SERVICES Rural Roadway Design Laboratory Testing Services
Urban Roadway Design Drilling Services
Interchange Design Engineering Services (sample should include MicroStation & GEOPAK
capabilities)
SURVEYING ENVIRONMENTAL SERVICES
GPS (sample should include equipment list) Hazardous Waste Site Analysis
SUE Preliminary Site Assessment
Route Location Surveys Detailed Site Reconnaissance/Site
Vangarde Sampling
Laboratory Services
PHOTOGRAMMETRY Remediation Services
Photogrammetric Services Underground Storage Tank Analysis
Aerial Photography Services Site Assessment
(sample should include equipment list)
Tank Removal/Disposal
BRIDGE DESIGN CSA/CAP
Bridges - Spans under 200’ Laboratory Services
Bridges - Spans over 200’ Site Remediation Services HYDRAULICS UTILITIES
Hydraulic Design - Bridges & Box Culverts Utilities by Others (Plans)
Hydraulic Design - Highways Utility Construction (Plans, Specs, & Estimates)
Hydrology
Storm Water Management OTHER
Scour Visualization
Safety & Health
Highway Design Branch continued…
October 1, 1995 (Rev. 2/14/03) -2a- PEFQUAL-1
CORPORATE HEADQUARTERS Highway Design Branch - Soils and Foundation Design NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists
Civil Engineers Hydraulics Engineers
Draftsmen/CADD Engineering Technicians
Geotechnical Engineers Surveyors
Safety & Health
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists
Civil Engineers Hydraulics Engineers
Draftsmen/CADD Engineering Technicians
Geotechnical Engineers Surveyors
Safety & Health
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send 2 samples of work for each new area marked to show your expertise with State DOTs.
GEOTECHNICAL ENGINEERING SERVICES
DESIGN SERVICES TESTING SERVICES (Submit complete design reports, list
of latest design software) (Submit complete testing reports, list
of latest equipment and software)
Deep and Shallow Foundation Design Pile Driving Analyzer
Retaining Walls Crosshole Sonic Logging (CSL)
Soil Nail Walls (SNW) Pile Integrity Test (PIT)
Tieback Walls Statnamic
Pile Panel Walls Osterberg Load Cell
MSE Walls Static Load Test
Cantilever, Fabric Walls Drilled Pier Inspection Device
Other (SID)
Vibration Monitoring
Soil Improvements Other
Slope Stability and Embankment
Settlements Design & Analysis
Landslides mitigation and Analysis
Rock Slope Design and Analysis
Tunnel Design
OTHER (for both)
Safety & Health Contact Person: Nancy L. Gay - 919/250-4001 Highway Design Branch [email protected] 1584 Mail Service Center Raleigh, NC 27699-1584
October 1, 1995 (Rev. 2/14/03) -3- PEFQUAL-1
CORPORATE HEADQUARTERS Construction Services NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Construction Technicians Surveyors
Civil Engineers Cost Estimators Transportation
Claims Analysts Draftsmen/CADD Engineers
CPM Schedulers Soils Engineers Safety & Health
Construction Managers Structural Engineers
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Construction Technicians Surveyors
Civil Engineers Cost Estimators Transportation
Claims Analysts Draftsmen/CADD Engineers
CPM Schedulers Soils Engineers Safety & Health
Construction Managers Structural Engineers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: CONSTRUCTION
Roadway Construction Engineering & Construction Contract Claim Analysis
Inspection Structures Construction Engineering & OTHER
Inspection Safety & Health
Contact Person: Patrick Riddle - 919/733-7174 [email protected] Contractual Services Section 1543 Mail Service Center Raleigh, NC 27699-1543
October 1, 1995 (Rev. 2/14/03) -4- PEFQUAL-1
CORPORATE HEADQUARTERS Traffic Engineering & Safety Systems Services
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Software Engineers Civil Engineers GIS Staff Draftsmen/CADD Structural Engineer Electrical Engineers Safety & Health Transportation Engineers NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Software Engineers
Civil Engineers GIS Staff
Draftsmen/CADD Structural Engineer
Electrical Engineers Safety & Health
Transportation Engineers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: TRAFFIC ENGINEERING OTHER Traffic Control & Pavement Marking Safety & Health Signals & Geometrics Sign Design Signal System Design Congestion Management Strategies Traffic Data Collection Intelligent Transportation Systems Signal System Timing Development &
Implementation
Signal Equipment Design/Application Contact Person: Kenneth W. Ivey, PE - 919/715-7736 [email protected] Traffic Engineering Branch 1561 Mail Service Center Raleigh, NC 27699-1561
October 1, 1995 (Rev. 2/14/03) -5- PEFQUAL-1
CORPORATE HEADQUARTERS Project Development & Environmental Analysis NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Public Involvement
Civil Engineers Quality Specialists Specialists
Draftsmen/CADD Community Planners GIS
NEPA/SEPA Practitioners Architectural Historians Environmental
Transportation Planners Soil Scientists Engineers
Archaeologists Biologists Safety & Health
Sociologists
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Public Involvement
Civil Engineers Quality Specialists Specialists
Draftsmen/CADD Community Planners GIS
NEPA/SEPA Practitioners Architectural Historians Environmental
Transportation Planners Soil Scientists Engineers
Archaeologists Biologists Safety & Health
Sociologists
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION:
PROJECT PLANNING OFFICE OF NATURAL ENVIRONMENT Preparation of NEPA/SEPA Environmental (ONE)
Documents Threatened & Endangered Species Survey
& Studies
OFFICE OF HUMAN ENVIRONMENT Ecological & Biotic Community Studies
(OHE) Wetland and Stream Delineation
Public Involvement Wetland, Stream, and Buffer Permitting
Indirect & Cumulative Impacts Assessment Wetland Mitigation Site Planning
Archaeological Resource Surveys Wetland Mitigation Site Design and
Historic Architectural Surveys of Standing Construction Oversight
Structures (Buildings & Bridges) Stream Biological Monitoring
Traffic Noise Analysis Stream Mitigation Site Plan
Air Quality Analysis Stream Mitigation Site Design and
Community Impact Assessment & Construction Oversight
Environmental Justice Freshwater Mussel Surveys
Safety and Health
Contact Persons: (919) 733-7844 Pam Rogers x 219, Beth Harmon x 312, Carl Goode 250-4092 [email protected] (Project Planning) [email protected] (Natural Environment) [email protected] (Human Environment) Project Development & Environmental Analysis 1548 Mail Service Center Raleigh, NC 27699-1548
October 1, 1995 (Rev. 2/14/03) -6- PEFQUAL-1
CORPORATE HEADQUARTERS GIS NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Surveyors (PLS)
Cartographers Safety & Health
Database Programmers
Drafting Technicians
GIS Analysts
GIS Programmers
GIS Technicians
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Surveyors (PLS)
Cartographers Safety & Health
Database Programmers
Drafting Technicians
GIS Analysts
GIS Programmers
GIS Technicians
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Cartography Linear Referencing System Development
Drafting Remote Sensing Application Development
Environmental Data Collection Remote Sensing Data Collection
GIS Analysis Remote Sensing Data Processing
GIS Application Development (Programming) Spatial Database Applications
GIS Data Conversion Spatial Database Development
GIS Data Validation Transportation Data Collection
GIS - Transportation Planning Applications Vehicle Routing
GPS Data Collection Video Logging
GPS Application Development (Programming) OTHER
Safety & Health
Internet GIS Application Development
Linear Referencing System Applications Contact Person: Forrest Robson, PE - 919/250-4188 x204 [email protected] Geographic Information Systems 1587 Mail Service Center Raleigh, NC 27699-1587
October 1, 1995 (Rev. 2/14/03) -7- PEFQUAL-1
CORPORATE HEADQUARTERS Bridge Maintenance NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Hydraulics Engineers
Civil Engineers Soils Engineers
Bridge Inspectors Bridge Engineers
Bridge Analysts Surveyors
Draftsman/CADD Environmental Engineers
Electrical Engineers Safety & Health
Geologists
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Hydraulics Engineers
Civil Engineers Soils Engineers
Bridge Inspectors Bridge Engineers
Bridge Analysts Surveyors
Draftsman/CADD Environmental Engineers
Electrical Engineers Safety & Health
Geologists
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: NBIS Municipal Bridge Inspection OTHER
Route Location Surveys Safety & Health
Bridge Design - Spans under 200'
Hydraulic Design - Bridges & Box Culverts
Hydrology
Scour
Geotechnical Laboratory Services
Geotechnical Drilling Services
Geotechnical Engineering Services
Erosion and Sediment Control
Stormwater Management
Hydraulic Design - Open Channels
Stream Restoration - Mitigation
Wetland Mitigation
Contact Person: John Emerson, PE - 919/733-4362 x13 [email protected] Bridge Maintenance Unit 1565 Mail Service Center Raleigh, NC 27699-1565
October 1, 1995 (Rev. 2/14/03) -8- PEFQUAL-1
CORPORATE HEADQUARTERS Materials & Tests NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Lumber Inspectors
Biologists Safety & Health
Certified Welding Inspectors
Chemists
Other Metals and Coatings Inspectors
OFFICE LOCATIONS
LOCATION OF OFFICES THAT WILL PROVIDE SERVICES
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Laboratory Services
Water/Wastewater/Soil/Sludge
Inspection Services
Inspection of Metal Products
Inspection of Wood Products
OTHER
Safety & Health
Contact Person: Jack E. Cowsert, PE - 919/733-7088 [email protected] Materials & Tests Unit 1564 Mail Service Center Raleigh, NC 27699-1564
October 1, 1995 (Rev. 2/14/03) -9- PEFQUAL-1
CORPORATE HEADQUARTERS Pavement Management NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Safety & Health
Pavement Design
Pavement Analysis
Pavement Distress
Identification
Pavement Management
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Safety & Health
Pavement Design
Pavement Analysis
Pavement Distress
Identification
Pavement Management
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Pavement Design OTHER
Pavement Condition Surveys Safety & Health
Pavement Analysis
Pavement Management Systems
Pavement Deflection Testing
& Backcalculation
Skid Testing
Profilometer & Reporting
Ground Penetrating Radar
& Analysis
Contact Person: Jerry Blackwelder, PE - 919/250-4094 [email protected] Pavement Management Unit 1593 Mail Service Center Raleigh, NC 27699-1593
October 1, 1995 (Rev. 2/14/03) -10- PEFQUAL-1
CORPORATE HEADQUARTERS Safety & Loss Control NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative
Environmental Engineers
Safety Engineers
Industrial Hygienist
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative
Environmental Engineers
Safety Engineers
Industrial Hygienist
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: ENVIRONMENTAL SERVICES OTHER
Hazardous Waste Site Analysis Safety & Health
Preliminary Site Assessment
Detailed Site Reconnaissance/Site
Sampling
Laboratory Services
Remediation Services
Underground Storage Tank Analysis
Site Assessment
Tank Removal/Disposal
CSA/CAP
Laboratory Services
Site Remediation Services
Contact Person: R. K. Andrews, Jr., CSP - 919/250-4200 x241 [email protected] Safety & Loss Control 1594 Mail Service Center Raleigh, NC 27699-1594
October 1, 1995 (Rev. 2/14/03) -11- PEFQUAL-1
CORPORATE HEADQUARTERS Statewide Planning NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Public Involvement
Civil Engineers Specialists
GIS Safety & Health
Transportation Engineers
Land Use Planners
Environmental Specialists
Transportation Modelers
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Public Involvement
Civil Engineers Specialists
GIS Safety & Health
Transportation Engineers
Land Use Planners
Environmental Specialists
Transportation Modelers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Transportation Planning OTHER
Traffic Forecasting Safety & Health
Model Development
Transportation Plan Development
Functional Design
Public Involvement
Environmental Analysis
Contact Persons: Mike Bruff, PE - 919/733-4705 / Laura Cove, PE - 919/715-5737 [email protected] [email protected] Statewide Planning Branch 1554 Mail Service Center Raleigh, NC 27699-1554
October 1, 1995 (Rev. 2/14/03) -12- PEFQUAL-1
Roadside Environmental - CORPORATE HEADQUARTERS Soil & Water Engineering Section NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Safety & Health
Civil Engineers
Agricultural Engineers
Hydraulic Engineers
Environmental Engineers
Draftsmen/CADD
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Safety & Health
Civil Engineers
Agricultural Engineers
Hydraulic Engineers
Environmental Engineers
Draftsmen/CADD
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: Erosion and Sediment Control OTHER
Hydrology Safety & Health
Stormwater Management
Hydraulic Design - Open Channels
Stream Restoration/Mitigation
Wetland Mitigation
Contact Person: David B. Harris - 919/733-2920 [email protected] Roadside Environmental Unit Soil and Water Engineering Section 1557 Mail Service Center Raleigh, NC 27699-1557
October 1, 1995 (Rev. 2/14/03) -13- PEFQUAL-1
Roadside Environmental - CORPORATE HEADQUARTERS Environmental Operations Section NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Draftsman/CADD
Environmental Engineers Safety & Health
Geologists
Certified Hazardous
Materials Managers
Civil Engineers
Surveyors
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Draftsman/CADD
Environmental Engineers Safety & Health
Geologists
Certified Hazardous
Materials Managers
Civil Engineers
Surveyors
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: ENVIRONMENTAL SERVICES OTHER
Hazardous Waste Site Analysis Safety & Health
Preliminary Site Assessment
Detailed Site Reconnaissance/Site
Sampling
Laboratory Services
Remediation Services
Underground Storage Tank Analysis
Site Assessment
Tank Removal/Disposal
CSA/CAP
Laboratory Services
Site Remediation Services
Contact Person: T. C. Niver, PG, CHMM - 1-888-457-0512 [email protected] Roadside Environmental Unit Environmental Operations Section 4809 Beryl Road Raleigh, NC 27606
October 1, 1995 (Rev. 2/14/03) -14- PEFQUAL-1
Rail Division - CORPORATE HEADQUARTERS Engineering & Safety and Operations Branches NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Environmental
Civil Engineers Hydraulics Engineers Engineers
Draftsmen/CADD Soils Engineers Architects
Traffic Engineers Bridge Engineers Construction
Railroad Engineers Surveyors Inspectors
Roadway Engineers Photogrammetrists Safety & Health
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists Environmental
Civil Engineers Hydraulics Engineers Engineers
Draftsmen/CADD Soils Engineers Architects
Traffic Engineers Bridge Engineers Construction
Railroad Engineers Surveyors Inspectors
Roadway Engineers Photogrammetrists Safety & Health
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: RAIL-HIGHWAY CROSSING OPERATIONS FACILITIES DESIGN
Traffic Separation Studies and Crossing AND MANAGEMENT
Evaluation Studies Passenger Station Design
Railroad Crossing Signal and Traffic Historic Passenger Station Renovations
Engineering Services Passenger Platforms
RAIL ENGINEERING Construction Administration
Track Design, Survey, and Layout Maintenance Facility
Railroad Signal System Plans Rail Facilities
Review of Engineering Drawings, Standards Rail Sidings
and Specifications Landscape and Streetscape Design
Rail Construction Project Inspection and
Management OTHER
Boundary and Location Surveys Safety & Health
Project Preliminary/Conceptual Plans and
Visualizations
Rail Corridor Maintenance Assessments,
Surveys, and Lease Studies
Rail Corridor Traffic Modeling and
Capacity/Feasibility Studies Contact Person: Arthur Petteway, PE - 919/715-3689
[email protected] Rail Division (Engineering & Safety Branch) 1556 Mail Service Center Raleigh, NC 27699-1556
October 1, 1995 (Rev. 2/14/03) -15- PEFQUAL-1
CORPORATE HEADQUARTERS Rail Division - Planning Branch NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Traffic Noise & Air Bridge Engineers
Civil Engineers Quality Specialists Public Involvement
Draftsmen/CADD Architect Historians Specialists
Transportation Engineers Geologists Transportation
Planners Hydraulic Engineers Modelers
Archaeologists Soils Engineers Environmental
Biologists Railroad Engineers Engineers
Safety & Health NEPA/SEPA
Practitioners NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Bridge Engineers
Civil Engineers Quality Specialists Public Involvement
Draftsmen/CADD Architect Historians Specialists
Transportation Engineers Geologists Transportation
Planners Hydraulic Engineers Modelers
Archaeologists Soils Engineers Environmental
Biologists Railroad Engineers Engineers
Safety & Health NEPA/SEPA
Practitioners
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: PROJECT PLANNING ENVIRONMENTAL SERVICES
Route Location & Feasibility Studies Natural Resources
Preparation of Environmental Documents Ecological & Biotic Community Studies
Rail Functional and Preliminary Design Threatened & Endangered Species
Studies of Economic and Fiscal Impact of Investigation
Rail Related Activities Wetland and Stream Delineations
Demand Modeling, Ridership, Revenue, Wetland and Stream Mitigation
Operating Costs for Commuter and Intercity Passenger Rail Operations
Site Planning
Safety & Health
Train Performance and Rail Line Capacity Cultural Resources
Analysis Archaeological Resource Surveys
Technical and Negotiation Assistance in Standing Historic Structure Surveys
Securing Rail Lines or Corridors Traffic Noise Analysis
Air Quality Analysis
Full NEPA/SEPA Documentation
Environmental Permits Acquisition Contact Person: Arthur Petteway, PE - 919/715-3689 (See page 13 for
[email protected] mailing address)
October 1, 1995 (Rev. 2/14/03) -16- PEFQUAL-1
CORPORATE HEADQUARTERS Program Development NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air
Quality Specialists Public Involvement
Specialists
Civil Engineers
Community Planners
GIS
Draftsmen/CADD
Architectural Historians
Environmental Engineers
Transportation Engineers
Soil Engineers
Safety & Health
Transportation Planners
Biologists
Hydraulics Engineers
Archaeologists
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Traffic Noise & Air Quality
Specialists Public Involvement
Specialists
Civil Engineers
Community Planners
GIS
Draftsmen/CADD
Architectural Historians
Environmental Engineers
Transportation Engineers
Soil Engineers
Safety & Health
Transportation Planners
Biologists
Hydraulics Engineers
Archaeologists
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: PROJECT PLANNING NATURAL ENVIRONMENTAL SERVICES
Route Location, Preliminary Design & Feasibility Studies
Threatened & Endangered Species Survey & Studies
Preparation of NEPA/SEPA Environmental Documents
Ecological & Biotic Community Studies
Traffic Projections
Wetland and Stream Delineation
Highway & Signal Capacity Analysis
Wetland and Stream Permitting
Traffic Projections
Wetland Mitigation Site Planning and/or Construction
HUMAN ENVIRONMENTAL SERVICES
Stream Biological Monitoring
Public Involvement
Stream Mitigation Site Planning &
Indirect & Cumulative Impacts Assessment
Restoration
Archaeological Resource Surveys
Freshwater Mussel Surveys
Historic Architectural Surveys of Standing Structures (Buildings & Bridges)
Traffic Noise Analysis
OTHER
Air Quality Analysis
Safety & Health
Community Impact Assessment & Environmental Justice
Contact Persons: Derrick W. Lewis, PE - 919/733-3690 x350 [email protected] Program Development Branch 1534 Mail Service Center Raleigh, NC 27699-1534
October 1, 1995 (Rev. 2/14/03) -17- PEFQUAL-1
CORPORATE HEADQUARTERS Equipment & Inventory Control Unit NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists
Civil Engineers Soils Scientists
Draftsmen/CADD Surveyors
Electrical Engineers Safety & Health
Environmental Engineers
NC OFFICE/S
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.) Administrative Geologists
Civil Engineers Soils Scientists
Draftsmen/CADD Surveyors
Electrical Engineers Safety & Health
Environmental Engineers
INDICATE TYPE OF PROJECTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: GEOTECHNICAL SERVICES OTHER
Laboratory Testing Services Safety & Health Drilling Services
Engineering Services
ENVIRONMENTAL SERVICES
Hazardous Waste Site Analysis Preliminary Site Assessment
Detailed Site Reconnaissance/Site
Sampling
Laboratory Services Remediation Services
Underground Storage Tank Analysis
Site Assessment
Tank Removal/Disposal
CSA/CAP Laboratory Services
Site Remediation Services
Contact Persons: Eric Motzno - 919/733-2220 [email protected] (Delivery) Equipment & Inventory Control Unit 4809 Beryl Road Raleigh, NC 27606 (Mail) 1566 Mail Service Center Raleigh, NC 27699-1566
October 1, 1995 (Rev. 2/14/03) -18- PEFQUAL-1
CORPORATE HEADQUARTERS Division Design/Construct Limited Services* NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental
Draftsmen/CADD Soils Engineers Engineers
Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
NC OFFICE/S (Attach organizational chart for the NC office/s w/employees & areas of expertise noted.)
NUMBER OF PERSONNEL BY DISCIPLINE: (If individual has more than one discipline, list primary only.)
Administrative Geologists Photogrammetrists
Civil Engineers Hydraulics Engineers Environmental
Draftsmen/CADD Soils Engineers Engineers
Transportation Engineers Bridge Engineers Safety & Health
Electrical Engineers Surveyors
INDICATE TYPE OF PROJE CTS FOR WHICH YOUR FIRM REQUESTS PREQUALIFICATION: If new firm, or existing firm adding new area of expertise, send a sample of work for each new area marked.
ROADWAY DESIGN TRAFFIC ENGINEERING Rural Roadway Design Traffic Control & pavement Marking
Urban Roadway Design Signals & Geometrics
(sample should include computer design Signing Design capabilities -MicroStation & GEOPAK preferred)
SURVEYING ENVIRONMENTAL ANALYSIS GPS (sample should include equipment list) Erosion and sedimentation control design
Subsurface Utility Engineering Wetland, stream, and riparian buffer
Route Location Surveys determinations
Vangarde Surveys for threatened/endangered species
Construction Surveys Permit application
Archeological surveys
HYDRAULICS
Hydraulic Design - Highways OTHER
Hydrology
Storm Water Management
* This prequalification page is for those firms who are
interested in performing design on small projects for a division office.
Contact Person: James W. Rand - 919/733-7621 Operations [email protected] 1537 Mail Service Center Raleigh, NC 27699-1537
October 1, 1995 (Rev. 2/14/03) -19- PEFQUAL-1
RÉSUMÉ (For key personnel that work and reside in NC only)
Name & Title:
Work Address:
Years experience: With This Firm With Other Firms
Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
RÉSUMÉ (For key personnel that work and reside in NC only)
Name & Title:
Work Address:
Years experience: With This Firm With Other Firms
Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
Duplicate if necessary
October 1, 1995 (Rev. 2/14/03) -20- PEFQUAL-1
RÉSUMÉ
(For key personnel that work and reside in NC only)
Name & Title:
Work Address:
Years experience: With This Firm With Other Firms
Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
RÉSUMÉ (For key personnel that work and reside in NC only)
Name & Title:
Work Address:
Years experience: With This Firm With Other Firms
Education: Degree(s)/Year/Specialization
Active Registration: Year First Registered/Discipline
Other Experience and Qualifications:
Duplicate if necessary
October 1, 1995 (Rev. 2/14/03) -21- PEFQUAL-1
ACTIVITIES FOR WHICH YOUR FIRM HAS PRIME RESPONSIBILITY List samples of work (prime & sub) your North Carolina office has performed in the past two years (i.e., NCDOT, municipal, private, etc.)
PROJECT AND TYPE OF WORK
LOCATION
NAME AND ADDRESS OF OWNER
FEE
DATE COMPLETED
TOTAL NUMBER OF PRESENT PROJECTS: TOTAL FEE: Duplicate if necessary
October 1, 1995 (Rev. 2/14/03) -22- PEFQUAL-1
MOST RECENT ACTIVITIES FOR WHICH YOUR FIRM PERFORMED CONSTRUCTION ENGINEERING & INSPECTION List all work (prime & sub) your North Carolina office is presently performing (i.e., NCDOT, municipal, private, etc.)
PROJECT AND TYPE OF WORK
LOCATION
NAME AND ADDRESS OF OWNER
FEE
COMPLETION DATE OF SERVICES
TOTAL NUMBER OF PROJECTS: TOTAL FEE: Duplicate if necessary
October 1, 1995 (Rev. 2/14/03) -23- PEFQUAL-1
FINANCIAL STATEMENT (For New and Reinstated Firms Only-Not Necessary for Updates)
Balance Sheet as of , 20 Date ¨ A Corporation
Firm Name ¨ A Partnership State in Which Incorporated ¨ Individual/Other
TOTAL CURRENT ASSETS TOTAL CURRENT LIABILITIES
(Including cash, bid deposits, notes, receivable stocks, bonds, inventories, interest receivable, life insurance)
(Judgments, accounts/notes payable owed to subcontractors, accrued taxes, accrued salaries and payrolls, accrued interest payable)
TOTAL FIXED ASSETS TOTAL FIXED AND OTHER LIABILITIES
(Net book value of plant, equipment and real estate)
(Including mortgage on plant equipment and real estate and other liabilities)
TOTAL OTHER ASSETS NET WORTH
(Non-business real estate, land, building improvements, miscellaneous)
(Including individual or partnership capital stock, surplus)
TOTAL ASSETS TOTAL LIABILITIES AND
NET WORTH
October 1, 1995 (Rev. 2/14/03) -24-
APPROVAL OF PERSONNEL The department shall have the right to approve or reject supervisory personnel assigned to a project. The engineers, business entity, or any subcontractor which are involved in the prequalification review process, listed on the Register of Qualified Firms, or are employed to provide services for the department shall not discuss employment opportunities or engage the services of any person or persons, now in the employment of the State without written and obtained consent of the department. The written consent must be requested through the employee's branch manager. In the event of engagement, the engineers, business entity, or their subcontractors shall restrict such person or persons from working on any of the contracted projects in which the person or persons were formerly involved in the contracting process while employed by the department. This restriction period shall be for the duration of the contracted project with which the person or persons was involved. "Involvement" shall be defined as active participation in any of the following activities:
§ drafting the contract
§ defining the scope of the contract
§ selection of the firm for services
§ negotiations of the cost of the contract (including calculating manhours or fees
§ administration of the contract
An exception to these terms may be granted when recommended by the Secretary and approved by the Board of Transportation. Failure to comply with the terms stated above in this section shall be grounds for termination of a contract(s) and/or not being considered for selection or work on future contracts for a period of one year.
October 1, 1995 (Rev. 2/14/03) -25-
CONFLICT OF INTEREST ASSESSMENT 1. Has your firm or any principal been indicted, pled guilty, or been convicted of any offense that
has resulted in your firm being debarred or suspended from performing work for any State, Local, or Federal Government during the past 5 years? Yes No If yes, attach a separate sheet(s) to this form giving the details involved.
2. Has any officer, employee, or member of your firm been indicted, pled guilty, or been convicted
of any illegal restraints of trade (including collusive bidding), during the past 5 years? Yes No If yes, attach a separate sheet(s) to this form giving the details involved.
3. Has your firm or any officer, employee, or member of your firm been debarred for violation of
various Public Contract Acts incorporating Labor Standards Provisions during the past 5 years? Yes No If yes, attach a separate sheet(s) to this form giving the details involved.
4. Is your firm under the protection of the bankruptcy court, has pending any petition in bankruptcy
court or have you made an assignment for the benefit of creditors? Yes No 5. List the principal officers of your firm, or if not a corporation, the owners. If there are more than
five (5), attach a list. Attach a brief résumé for each individual listed.
Name
Position
Years of Experience
Type of Work Experience
1. 2. 3. 4. 5.
6. List the principal members of your firm that are involved in the managerial or policy making
decisions of your firm if other than those listed above. If there are more than five (5), attach a list. Attach a brief résumé for each individual listed.
Name
Position Years of
Experience Type of Work Experience
1. 2. 3. 4. 5.
7. List all owners (including individuals, companies or corporations) of applicant's firm and the
percent of ownership of each, and any successive parent entities. If there are more than five (5), attach a list. Include only owners who have 10% or more ownership.
Name of Individual Percent of Ownership
1. 2. 3. 4. 5.
October 1, 1995 (Rev. 2/14/03) -26-
8. List each of the individuals identified in "7" who has financial interest in any other private consulting firm in this or another state; name the other firm and list the percentage of ownership of each owner listed in "10". If more than five (5), attach a list.
Name of Individual or Firm
Name of Other Firm
Percent of Ownership
1. 2. 3. 4. 5.
9. List any officer or member of the firm in a management or policy making position listed in "7" and
"8" who also is an officer or serves in the management of any other private consulting firm in this state or any other state. List the officer or manager and the firm as well as the position in the other firm. If more than five (5), attach a list.
Name of Individual Name of Firm Position Held
1. 2. 3. 4. 5.
10. List all affiliates of the private consulting firm including, but not limited to: (1) joint ventures, (2)
subsidiaries, (3) parent company, (4) companies owned or controlled by the parent company, (5) any company or firm having some mutual owners as the applicant which does business with the applicant. If more than five (5), attach a list.
Name of Firm Address Relationship
1. 2. 3. 4. 5.
11. List major creditors of the private consulting firm, of its owners, and of all of its affiliates with
normal banking relationships. If more than five (5), attach a list.
Name Address
1. 2. 3. 4. 5.
12. List major creditors (or endorsers) of the private consulting firm, of its owners, and of all of its
affiliates other than normal banking relationships that may have control over the firm. If more than five (5), attach a list.
Name Address
1. 2.
October 1, 1995 (Rev. 2/14/03) -27-
3. 4. 5.
13. List any substantial landowners with which the private consulting firm, its owners, and its
affiliates have a relationship. If more than five (5), attach a list.
Name Address Relationship
1. 2. 3. 4. 5.
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Firm Name
By:
Title: STATE OF COUNTY OF On this day of , 20 , personally appeared before me for (Official of Firm) (Firm Name) who signed the foregoing affidavit in my presence and made oath to the truth of the statement herein contained.
Name of Notary My commission expires