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SNOW BELT HOUSING COMPANY, INC.
CONTRACTOR’S ELIGIBILITY CERTIFICATION
Name of Company: __________________________________ Home No: ________________
Business Address: _____________________________________ Cell No: ______________
Fax #: _____________________ E-Mail Address: __________________________________
Type of Company: Individual/Sole Owner ______ Corp ______ Partnership ______
Principal Owner: ______________ _____________ Number of Owners: ____________
Number of Years in Business: _______________ Number of Employees: __________
Federal ID#: ______________________ Social Security #: __________________
CREDIT REFERENCES
Bank: ____________________________________ Phone: ______________________
Complete Address: ____________________________________________________________
Supplier #1: ____________________________________ Phone: ______________________
Complete Address: ____________________________________________________________
Supplier #2: _____________________________________ Phone: ______________________
Complete Address: ___________________________________________________________
Please attach a $10.00 processing fee (payable to Snow Belt Housing) which includes the cost of a Credit Bureau Report.
Job References: Please list job references on the next page of this form.
Insurance Information: Attach a copy of your Certificate of Insurance showing general or comprehensive liability coverage (must be current and at least $600,000).
Attach Proof of Workmen’s Compensation: Insurance coverage must be current for all applicants.
Attach Proof of Lead Based Paint Qualifications for yourself and all employees or a firm license.
Principal’s Signature: ____________________________________ Date: ________________
Our Company can do the following types of work: References: List 2 names with
Phone numbers, as indicated below,
_____ Well drilling (NYS DEC Certification required) for each category checked.
_____ Foundations (concrete, block) Masonry: ___________________
_____ Repair/re-point of stone walls ____________________________
_____ Bilco style cellar entrances ____________________________
_____ Chimneys (masonry, double/triple wall)
_____ Siding (repair, replacement and new installation) Siding: ______________________
_____ Fascia & Soffit (wood, vinyl and aluminum) _____________________________
_____ Gutters & downspouts _____________________________
_____ New windows Windows/Doors: ______________
_____ Vinyl replacement windows _____________________________
_____ Window repairs, re-glaze, install storms _____________________________
_____ Doors (exterior, interior, storms)
_____ Roofing (strip/sheath/re-roof) Roof: ________________________
_____ Mobile home (add a roof or roof over) ______________________________
_____ Gutters & downspouts ______________________________
_____ Electrical (services, panels, wiring) Electrical: ____________________
_____ Smoke alarms (hard wired and battery) ______________________________
_____ Plumbing (whole house, supply and drains) Plumbing: ____________________
_____ Water pumps & pressure/storage tanks ______________________________
_____ Jet & submersible ______________________________
_____ Heating systems (electric, gas and oil) Heating: ______________________
_____ Forced air, boilers, electric ______________________________
_____ Septic systems (repair/replace/new installation) Septic System: _________________
_____ Excavation (backhoe, dozer, dump truck) ______________________________
_____ Structural repairs (joist, beam, porch, deck, steps, stairs)
Other: List 2 names with phone
_____ Small plumbing repairs numbers for other work that you
have done, other than those items
_____ Insulation (blown-in, fiberglass) as listed above:_________________
______________________________
_____ Sheet rock (walls/ceilings/spackling) ______________________________
_______________________________
_____ Painting or staining (exterior) ______________________________
_____ Lead based paint stabilization & safe work practices
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THIS SPACE FOR OFFICE USE ONLY!
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Please return this form to: Snow Belt Housing Company, Inc/7500 South State Street/Lowville NY 13367. (You will then be asked to fill out a W-9 form or you can download it online)
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