Community Development Department

Small Works Roster Applications Qualifications/Requirements;

Firms on the SWR must be able to show proof of:

• Insurance, naming City of Hoquiam as additional insured, prior to the performance of a specific contract.
• A performance Bond prior to performance of a specific job
• Appropriate Licensing.

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CITY OF HOQUIAM SMALL WORKS ROSTER APPLICATION

COMPANY ______________________________________________ 

MAILING ADDRESS ___________________________________ 

STREET ADDRESS (IF DIFFERENT) __________________________ 

___________________________ZIP ____________________ 

TELEPHONE NUMBER _______________________________________ 

BANKING REFERENCE NAME OF BANK _________________________ 
Address____________________________________ZIP________________________ 

TYPE OF OWNERSHIP Corporation      Single Proprietorship     Partnership 

• MINORITY AND WOMEN OWNED BUSINESS          MBE           WBE
  BUSINESS LICENSE #__________ 
  CONTRACTORS LICENSE#_________________________ 
  WASHINGTON STATE TAX#________________________  
  CHECK BOXES THAT DESCRIBE TYPES OF WORK YOUR FIRM  
  QUALIFIES TO PERFORM: 
• General Contractor 
• Building 
• Concrete Placement Finishing 
• Electrical 
• Heating 
• Masonry 
• Painting 
• Paving 
• Road Grading 
• Cleaning/Grubbing 
• or Marina 
• Plumbing 
• Roofing 
• Storm Drainage 
• Sewer Systems 
• Street Repair and Construction 
• Illumination 
• Water Systems 
• Other_________
Describe experience and qualifications : 
__________________________________________________ 

__________________________________________________ 

__________________________________________________ 
List 5 references : 
_1___________________________2____________________ 

_3___________________________4____________________ 

_5_______________________________________________ 

Other information regarding your firm's ability to satisfactorily perform a contract with the City of Hoquiam.  
___________________________________________________ 

___________________________________________________ 

___________________________________________________ 

By signature below, I acknowledge that I have read and understand the requirements described in this application and to the best of my knowledge. information provided is a true representation of the named firm's ability to perform any contracts which may result by submittal of this application. ______________________           _____________ 
Name & Title of Preparer/typed/printed                    Signature 

STATE OF WASHINGTON  ) 
                                            ) ss. 
County of                              ) 

       On this day personally appeared before me_________________________ known to me to be the individual described in and who executed the within and foregoing instrument,  
and acknowledged that _______________________signed the same  
as his/her free and voluntary act and deed, for the uses and purposed therein mentioned.  

Given under my hand and official seal this ______day of _________, 20___  

Notary Public in and for the State of Washington residing at __________________________________