FLORIDA DEPARTMENT OF TRANSPORTATION (FDOT) Submit completed form to

Transcription

1 FLORIDA DEPARTMENT OF TRANSPORTATION (FDOT) Submit completed form to Page 1 of 7 You must first be registered in MyFloridaMarketPlace (MFMP) before we can add you to the small business database. Information to register is available here: Please note: Completion of this form and listing on the small business site does not constitute Contractor Prequalification with FDOT. Contractors who wish to become qualified with FDOT in construction work classes should go to: Business Name JANUS RESEARCH, INC. Business Address 1107 N Ward Street Tampa FL Street City State Zip Mailing Address 1107 N Ward Street Tampa FL Street City State Zip Telephone (813) Fax (813) Other Contact Person Kenneth Hardin ken_hardin@janus-research.com Date Business Established 1979 FDOT Districts/Counties I am interested in performing work in: (Please check all that apply) District 1 Alachua DeSoto Highlands Marion Santa Rosa District 2 Baker Dixie Hillsborough Martin Sarasota District 3 Bay Duval Holmes Miami-Dade Seminole District 4 Bradford Escambia Indian River Monroe St. Johns District 5 Brevard Flagler Jackson Nassau St. Lucie District 6 Broward Franklin Jefferson Okaloosa Sumter District 7 Calhoun Gadsden Lafayette Okeechobee Suwannee Turnpike Charlotte Gilchrist Lake Orange Taylor Central Office Citrus Glades Lee Osceola Union Clay Gulf Leon Palm Beach Volusia Collier Hamilton Levy Pasco Wakulla Columbia Hardee Liberty Pinellas Walton Hendry Madison Polk Washington Hernando Manatee Putnam Federal Employer Identification Number Legal Structure Corporation Limited Liability Company (LLC) Partnership Sole Proprietorship List All Owners of the Business: NAME TITLE PERCENT OWNED Kenneth Hardin President 100 Majority Owner s Gender Male Majority Owner s Race Caucasian Note: Providing this information will not affect the award of a contract. The information will be used for statistical purposes only.

2 Page 2 of 7 FDOT DBE CERTIFICATION SPECIALTY/NAICS CODE SHEET WITH CAP SIZES CONSTRUCTION & MAINTENANCE Highway, Street, and Bridge Construction Asphalt Roadway $ 15 Asphalt Concrete Curb $ 15 Concrete Gutter, Curb Elements, & Traffic Separators $ 15 Concrete Barrier Wall $ 15 Concrete Ditch & Slope Pavement $ 15 Inlets, Manholes & Junction Boxes $ 15 Pipe Culverts & Storm Sewers $ 15 Structural Plate Pipe & Pipe Arch Culverts $ 15 Underdrains $ 15 Guardrail $ 15 Highway Signing $ 15 Bridge Deck Joints $ 15 Foundation, Structure, and Building Exterior Contractors Reinforcing Steel $ 15 Structural Steel $ 15 Masonry Contractors $ 15 Roofing Contractors $ 15 Other Foundation, Structure, and Building Exterior Contractors $ 15

3 Page 3 of 7 Specialty Trade Contractors All Other Specialty Trade Contractors $ 15 Miscellaneous Asphalt Pavement $ 15 Concrete Sidewalk $ 15 Pipe Handrail Furnishing, erecting, and painting pipe handrail $ 15 Temporary Erosion Control $ 15 Plastic Filter Blanket (Geotextile) $ 15 Riprap $ 15 Fencing $ 15 Maintenance of Traffic $ 15 Highway Delineators and Object Markers $ 15 Reflective Pavement Markers $ 15 Painting Traffic Stripes/Painted Pavement Markings $ 15 Thermoplastic Traffic Stripes and Markings $ 15 Crash Cushions $ 15 Site Preparation Contractors Clearing & Grubbing $ 15 Excavation & Grading $ 15 Structures Foundations $ 15 Landscaping Services Litter Removal and Mowing $ 15 Muck Blanket & Topsoil $ 15 Performance Turf/Sodding $ 15 Landscape Installation $ 15 Other Heavy and Civil Engineering Construction Timber Structures $ 15 Utility System Construction Water and Sewer Line and Related Structures Construction $ 15 Water and Sewer Line and Related Structures Construction $ 15

4 Page 4 of 7 Electrical Contractors and Other Wiring Installation Contractors Electrical Wiring $ 15 Traffic Control Signals and Devices $ 15 Highway Lighting Systems $ 15 Navigation Lights for Fixed Bridges $ 15 Painting and Wall Covering Contractors Coating Structural Steel $ 15 Bridge Painting $ 15 Specialized Freight Trucking Specialized Freight (except Used Goods) Trucking, Local $ 15 Specialized Freight (except Used Goods) Trucking, Long-Distance $ 15 Materials Supply Must meet definition of "Regular Dealer" as defined in Rule 14-78, Florida Administrative Code and 49 Code of Federal Regulation Part 26. Brick, Stone, and Related Construction Material Merchant Wholesalers $ 15 Other Merchant Wholesalers $ 15 Commercial and Institutional Building Construction Toll & Service Plaza Facilities $ 15 Storage Facility, Building Addition $ 15 Office Building, Shop/Warehouse $ 15 Building Equipment Contractors Plumbing $ 15 Heating and Air Conditioning $ 15 Other Building Equipment Contractors $ 15 Building Finishing Contractors Drywall and Insulation Contractors $ 15 Flooring Contractors $ 15 Installation of Tile $ 15 CONTRACTURAL SERVICES Architectural Engineering Related Services

5 Laboratory Testing Facilities Non-Prequalified Firm Page 5 of 7 Drafting/CADD Services Non-Prequalified Firm Underwater Bridge Inspections/All Other Support Services Non- Prequalified Firm Traffic Data Services/Other Scientific and Technical Consulting Services Non-Prequalified Firm Consultant Engineering & Inspection (CEI) Related Services Technical Services Related to CEI (e.g. Inspectors) Non-Prequalified Firm Administrative and General Management Consulting/Financial Services Non-Prequalified Firm Environmental Services Environmental Consulting Services Non-Prequalified Firm Remediation Services, Asbestos Surveys and Abatement Services Non- Prequalified Firm Energy Consultant Services Non-Prequalified Firm Hazardous Waste Services Non-Prequalified Firm Mitigation Services Non-Prequalified Firm Management and Financial Services Certified Public Accountants Economic Consultant Services Educational Support Services/Education Consultant Administrative and General Management Consulting/Financial Services Human Resources Consulting Services/Personnel Services Public Relations Agencies/Services Professional and Management Development Training Services Temporary Help Services/Employment Agencies Computer Systems Design and Related Services Custom Computer Programming Computer Systems Design Services Computer Facilities Management Services/Data Processing Consultants Other Computer Related Services

6 Page 6 of 7 Right of Way Services Title, Abstract and Settlement Offices Non-Prequalified Firm Real Estate Appraisers Non-Prequalified Firm Other Activities Related to Real Estate Non-Prequalified Firm Property Management Services - Nonresidential Property Managers Non- Prequalified Firm Services to Building and Dwellings Landscaping/Lawn Care Services Janitorial Services/Commercial Cleaning Other Services to Buildings and Dwellings Miscellaneous Business Services Other Management Consulting Services/Business Services Not Elsewhere Classified (NEC) Other Business Service Centers (including Copy Shops)/Reprographics Security Guard and Patrol Services Research and Development in the Social Sciences and Humanities/Archeology Services *Size cap refers to the average annual gross receipts over the last three years (including affiliate businesses).

7 IMENT OF TMNSPORTATION SiIIALL BUSINESS AFFIDAVIT CERTIFICATION FOR ROAD AND BRIDGE CONTRACTS AND ALL OTHER NON.PROFESSIONAL SERVICES CONTRACTS 27mO{1 occ - 03/14 Page7 of7 t, Kenneth Hardin am an owner or duly authorized representative of JANUS RESEARCH (Proposer/name of business), and I do hereby declare: This business: I Meets th3 cdteria for a small business as defined by the Department. The criteria for a 6mall business can be bund at hftp:/ammlr.dot.state.fl. us/equalopportunityoffi ce/sizestandards.shtm. Gross revenues, three year average (include affiliate businesses) $ 2.1 Million The Department will use itb own definilion for a small business. Th3 Deparlment's small business size standard is established as $'15 million for Road and Bridge Contracts and $6.5 million for all odrcr nonprcf4sional s3rvlces contects, regardles8 of rvotk type. A business detemines lheir size by averaging lheir annual gross receipts over lhe last three yeab (include affiliate businesses as darined in Sedion , F.S.). lf the av rage gross receipts are under the size slandards, as defined by the Department, lhe business meets the D padments delinition of a small business. The undersigned hereby authorize(s) and request(s) any person, firm or corporation to fumish any pertinent information requested by the Siate of Florida Dspartnent of Transportation deemed necessary to verify the statemenb made in this afidavit or garding the ability, standing and genoral rputation of the Proposer. I declare, under penalty of perjury, that the information provided above and any supporting documents are true and accurate to the best of my knorvledge. OwnerlAuthoized Represen tative Signatu rc Jufv Date Kenneth Hardin. President Owner/Authoized Representative Pinted Name & Title COUNTY OF Before me, the above signed me or has produced that s*': represent pe,.sonarrv?ppeared knnnrt lmt&in, who is ) identification and is duly sworn, deposes and says (business). Sworn and subscribed to before me this p\ ulo.i+ Note: This form is to be used solely for rcad and brldge conabuction finn! and all o6rer non-prcf3sslonal semcea flrms. lf you are a pr qualified professional services firm and rrculd lik6 to be added to the small business database for professional services firms, please complete the Small Business Affidavit Certification br Preoualified ProFssional Services Firms. # {3.