TP-21834 (6/5/2012)
M innesota Department of Transportation
Request to Sublet Form (Standard Specification 1801)
Prime Contractor Information
Prime Contractor:
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Telephone Number: ( )
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State Project Number:
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Fax Number: ( )
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Project Location:
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Email:
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Important Notices and Instructions
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The Prime Contractor must complete all sections of this form, acquire all applicable signatures, and submit it to the Project Engineer (P.E.) 10 days prior to the first day of work for each Subcontractor. The Prime Contractor may attach additional sheets, or use the Request to Sublet Summary Form on the Labor Compliance Unit website (LCU); http://www.dot.state.mn.us/const/labor/documents/contractdocs/rtssummary.xls
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The Prime Contractor will ensure compliance with MnDOT’s subcontracting requirements under MnDOT Standard Specifications for Construction, Section 1801 Subletting of a Contract, applicable to the contract and any additional supplemental 1801 provisions listed in the contracts. .
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A First Tier Subcontractor may sublet up to 50 percent of its original Contract.
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A Second Tier Subcontractor may not sublet any portion of its work under the Contract.
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Upon approval, the P.E. will sign the form and provide a copy to the Prime Contractor.
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Upon request, the Prime Contractor will provide a copy of its written subcontracts to the P.E. or the Department.
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Each Subcontractor must submit an IC-134 form to the Prime contractor and the Prime contractor shall submit the necessary IC-134 forms to the Department before the State of Minnesota or its Subdivisions will issue final payment.
First Tier Subcontractor Information
First Tier Subcontractor:
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SWIFT Vendor ID:
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Street Address:
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Federal Tax I.D. Number:
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City, State, Zip Code:
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State Tax I.D. Number:
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Telephone Number: ( )
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Email:
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Fax Number: ( )
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Certified DBE Contractor: Yes No
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Specification or Item No.
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Specification or Item Description
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Quantity
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Unit of
Measurement
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Unit
Price
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Amount
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The Prime Contractor and/or First Tier Subcontractors shall not sublet any portion of its Contract without prior written consent from the P.E.
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%
Total
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$
Total
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Second Tier Subcontractor Information
Second Tier Subcontractor:
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SWIFT Vendor ID:
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Street Address:
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Federal Tax I.D. Number:
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City, State, Zip Code:
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State Tax I.D. Number:
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Telephone Number: ( )
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Email:
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Fax Number: ( )
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Certified DBE Contractor: Yes No
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Specification or Item No.
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Specification or Item Description
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Quantity
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Unit of
Measurement
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Unit
Price
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Amount
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$
Total
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Print Name and Title of Prime Contractor Representative
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Signature Date
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As a representative of the Prime Contractor, I hereby certify that the information described on this form is truthful and accurate to the best of my knowledge and that: All subcontracts are in writing and contain the appropriate requirements and provisions from the prime contract for the work performed by the individual subcontractor which includes: Special Provisions Division A, Federal and/or State wage determinations and the State certified truck rental rates. All subcontractors have viewed the Prevailing Wage Pre-construction videos and meeting agenda located on the MnDOT, LCU website prior to signing this document. All subcontractors are meeting the requirements of Minn. Stat. 16C.075 E-Verify and I have verified that all subcontractors have not been suspended or debarred by any governmental agency.
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Signature Date
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As a representative of the First Tier Subcontractor, I hereby certify that: All company information listed in the First Tier Subcontractor Information area above is true and accurate, I’ve reviewed our written subcontract with the prime contractor and understand all applicable contract requirements and specifications for the work we will be performing on the contract, which include but are not limited to: Special Provisions Division A, Federal and/or State wage determinations, State certified truck rental rates, I have also viewed the Prevailing Wage Pre-construction video and meeting agenda on the MnDOT, LCU website and I have passed all appropriate prime contract requirements and specifications in a written subcontract onto all Second Tier Subcontractors.
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Print Name and Title of Second Tier Subcontractor Representative
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Signature Date
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As a representative of the Second Tier Subcontractor, I hereby certify that: All company information listed in the Second Tier Subcontractor Information area above is true and accurate, I’ve reviewed our written subcontract with the First Tier Subcontractor and understand all applicable prime contract requirements and specifications for the work we will be performing on the contract, which include but are not limited to: Special Provisions Division A, Federal and/or State certified prevailing wage determinations, State certified truck rental rates. I have also viewed the Prevailing Wage Pre-construction video and meeting agenda on the MnDOT, LCU website.
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Print Name and Title of Project Engineer
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Signature Date
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As a representative of the Department, I approve the Prime Contractor’s utilization of the above-mentioned Subcontractors. Additionally, the Prime Contractor has complied with the terms established in Mn/DOT Standard Specifications for Construction, Section 1801.
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All persons signing this form understand that willful falsification of this document may result in civil and/or criminal prosecution under federal and/or state law. See Minnesota Statutes 16B, 161.315 Subdivision 2, 177.43 Subdivision 5, 177.44 Subdivision 6, 609.63; or the United States Code 18 U.S.C. 1001, 31 U.S.C. 231, CFR 5.12.
For additional information, visit the Labor Compliance website at: http://www.dot.state.mn.us/const/labor/
Pre-Construction Meeting Videos and Agenda link: http://www.dot.state.mn.us/const/labor/resources.html#pre-construction
Debarment links; State: http://www.mmd.admin.state.mn.us/debarredreport.asp Federal: https://www.epls.gov/ |
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