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Grants Contractor Application
This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Company and Contact Information
This section is complete
This section is incomplete
2.
Owners and References
This section is complete
This section is incomplete
3.
Disclosures
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This section is incomplete
4.
Contractor Supplement
This section is complete
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Company and Contact Information
Company Name
*
Company Type
*
Corporation
Partnership
Privately Owned
Number of Years in Business
*
DUNS Number/CAGE Code
*
If you do not have a DUNS Number/CAGE Code, visit www.sams.gov to register.
Contact Person
*
Contact Person Position
*
Contact Person Phone Number
*
Street Address
*
City
*
State
*
Zip Code
*
Email
*
Phone
*
Fax
*
Construction Experience
*
Please indicate if experience is new construction, rehabilitation, or renovation.
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Owners and References
Corporate Officers, Partners or Owners
Name
*
Title
*
Social Security Number
*
Name
Title
Social Security Number
Name
Title
Social Security Number
Name
Title
Social Security Number
Business References
Please list local banks and/or suppliers with whom your company has conducted business in the past 24 months.
Name
*
Address
*
Phone Number
*
Name
Address
Phone Number
Name
Address
Phone Number
Name
Address
Phone Number
Customer References
Please list customers with whom you have done business in the past 24 months.
Name
*
Address
*
Phone Number
*
Dollar Amount
*
Name
Address
Phone Number
Dollar Amount
Name
Address
Phone Number
Dollar Amount
Name
Address
Phone Number
Dollar Amount
All references will be verified
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Disclosures
Have you ever filed for bankruptcy?
Yes
No
The undersigned contractor certifies that all information given herein is correct and that the information may be verified from any source and further agrees:
1. That the State of Utah contractors class (indicated below) and bond therefore are current and agrees to maintain current status of all licenses and bonds as required by West Valley City.
*
License Class
2. That the contractor will perform the work in accordance with the description of work, general specifications and applicable City, State, or County codes and zoning regulations and be subject to final inspection by a West Valley City Building Inspector.
3. That if the work performed by the contractor is found to be unsatisfactory or if the contract relations between the contractor, homeowner, or other parties is found to be unsatisfactory, West Valley City may remove their name from the list of contractors without notice.
4. Copies of the contractor's licensed Section 3 Business Certification must be uploaded as attachments with this application.
License
*
Section 3 Business Certification
*
Download a Section 3 Business Certification Form
Section 3 Business Certification
5. Copies of the W9 and proof of Workman's Compensation & Insurance must be submitted to be included as a Preferred Contractor but do not need to be attached. Documentation may be submitted separately and must be submitted before beginning work.
W9
Download an IRS W9 Form
IRS W9 Form
Workman's Compensation & Insurance
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Contractor Supplement
State License Number
*
State License Type
*
Number of Years as a Contractor
*
Federal Tax ID Number
*
Please check the appropriate items:
*
This information will be used for statistical purposes.
Male
Female
Handicapped
Disabled
Veteran
Caucasian
Hispanic
African American
Pacific Islander
American Indian
Asian
Other
General Instructions
1) The contractor must meet all State of Utah licensing requirements. This also requires that proof of adequate liability insurance and workman's compensation coverage be provided. 2) The Contractor must obtain all required building permits prior to starting work. 3) All workmanship must conform to the Program's guidelines, building codes and be of acceptable quality.
Digital Signature & Acknowledgement
Name
*
Completion of the Name, title and date fields constitute your digital signature.
Title
*
Date
*
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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