dokumen kualifikasi pengawasan

32
STANDAR DOKUMEN KUALIFIKASI PENGADAAN JASA KONSULT ANSI (BADAN USAHA)

Upload: torpin-kibaid

Post on 13-Apr-2018

251 views

Category:

Documents


2 download

TRANSCRIPT

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 1/31

STANDAR DOKUMEN KUALIFIKASIPENGADAAN JASA KONSULTANSI

(BADAN USAHA)

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 2/31

D O K UM E N K U AL I F I K A S I

Nomor : ………………………………………………

Tanggal : ! D"#"m$"r %&

'n'

P"nga*aan

P""r+aan Pengawasan Pembangunan Jalan Poros Desa Kawasan SP 

 Distrik Mimika Kabupaten Mimika

P"+a$a P"m$'a Kom,m"n : PENGEMBANGAN KAWASAN PERMUKMAN

PERDESAAN 

Sam,nal : !P"A KAR#A

K"m"n"r,an P""r+aan Um'm

Ta-'n Anggaran: %&%

K E M E N T E R I A N P E K E R J A A N U M U M

DIREKTORAT JENDERAL CIPTA KARYASATKER PENGEMBANGAN PERMUKIMAN DAN PERBATASAN PAPUAPELAKSANAAN KEGIATAN PENGEMBANGAN KAWASAN PERMUKIMAN PERDESAANAlamat : Jln. Sumatera Nmr. !" D# I$ Tel%. &'()*+ ""'!,' - a/. &'()*+ ""'!,' Ja0a%ura

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 3/31

DAFTAR ISI

BABI UMUM .................................................................................... 1

BABII PENGUMUMAN PRAKUALIFIKASI ....................................... 3

BAB III INSTRUKSI KEPADA PESERTA (IKP) .................................. 4

BABIV LEMBAR DATA KUALIFIKASI(LDK) .................................... 15

BAB V SURAT PERJANJIAN KEMITRAAN ..................................... 17

BAB VI PAKTA INTEGRITAS…………………………………………… 19

BAB VII FORMULIR ISIAN KUALIFIKASI …………............................ 22

BAB VIII PETUNJUK PENGISIAN FORMULIR ISIAN

KUALIFIKASI ........................................................................ 2

BABI! TATA "ARA EVALUASI KUALIFIKASI ................................ 31

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 4/31

BAB. I UMUM

 A. D#$%&' K%*+,+$-+ ++ +-%-% /'0-0$ P'0%0 P0'-+' R'%/*+$I#'-+ N#&#0 54 T% 21 ' P' B06J- P'&'0+.

B. D*& D#$%&' K%*+,+$-+ ++ +'0%$ ''0+ +-+* -+$-'/+ /'0+$%8

/ Ja#a Kon#'lan#, 8 - *: 0#,'-+#* :&'&/%%$ $'*+ '0'% +/'0/+/+ $'+*&% : &'%&$: #* +$'0 (brainware);

< Harga P"r,raan S"n*,r, (HPS) 8 -+* '0+% -'*%0% =#*%&''$'0 +$*+$ ' >0 S%+&/ ' -'*%0% /'/ $ $'%%;

/ K"m,raan 8 $'0 -& %- 0 ':'+ :&-+<&-+ +$ &'&%:+ $$'?+/ % ?/ : '*-/'0-0$ '0+ '0%*+-;

/ LDK 8 L'&/0 D K%*+,+$-+;/ Pan,,a P"nga*aan 8 K'*#&#$ K'0 : /'0,%-+ %%$

&'*$-$ '&+*+ ':'+/06- *& P'B06J-.

". I-+ D#$%&' K%*+,+$-+ &'*+%+81. U&%&;2. P'%&%& P0$%*+,+$-+;3. I-0%$-+ K' P'-'0;4. L'&/0 D K%*+,+$-+;5. P$ I'0+-;@. F#0&%*+0 I-+ K%*+,+$-+;7. P'%%$ P'+-+ F#0&%*+0 I-+ K%*+,+$-+;. T "0 E=*%-+ K%*+,+$-+.

D. P' &'**%+ 0$%*+,+$-+ ++ +/+:+ 0+ -%&/'0 ' :'0%& *& LDK.

E. P++ P' &'%&%&$ '*$- 0$%*+,+$-+ &'**%+ *&website ???.%.#.+ '%&%& 0'-&+ %%$ &-:0$ P#0*P' N-+#* &'**%+ LPSE.

F. P0$%*+,+$-+ ++ '0/%$ ++$%+ #*' -'&% '-'0 : /'0/'%$/ %-.

BAB II PENGUMUMAN PRAKUALIFIKASI

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 5/31

PENGUMUMAN PRAKUALIFIKASI

N#&#0 8 &012gm/2ra1on#l1,m/2a2'a12.&01%&

P++ P' PPK. P''&/ K?- P'0&%$+& P'0'-$ &'*$-$ P0$%*+,+$-+ %%$ $' '$'0 - $#-%*-+ -'/+

/'0+$%8

. Pa" P""r+aan

N& $' '$'0 8 P"nga3a#an P"m$ang'nan Jalan Poro# D"#a

Ka3a#an SP D,#r, M,m,a Ka$'2a"n M,m,a

L+$% '$'0 8 P"nga3a#an P"m$ang'nan Jalan Poro#.

N+*+ T#* >PS 8 Rp$ %&%$&''$'''('' )Seratus enam pulu* satu 

 +uta

enam ratus ribu rupia*,

S%&/'0 ' 8 APBN Ta-'n Anggaran %&%

%. P"r#4araan P"#"ra

P'&+*+ ++ '0/%$ ++$%+ #*' B U- : &'&+*+$+ ++ %- K'+*

$*-+,+$-+ B+ J- I-'$-+ $%*+,+$-+ J- I-'$-+.

5. P"n*a6aran *an P"ngam$,lan Do'm"n K'al,6,a#,8

>0+6T* 8 K&+- 15 D'-'&/'0 211 -.. K&+- 22 D'-'&/'0 211

C$% 8 9. C+ -. 15. C+.

T'& *& 8 J*. S%&'0 N#. 15 D#$.IV J:%0 < P%

D'&+$+ +-&+$ %%$ &'+ '0+.

J:%0 D'-'&/'0 211

Pan,,a P"nga*aan

K E M E N T E R I A N P E K E R J A A N U M U M

DIREKTORAT JENDERAL CIPTA KARYA

SATKER PENGEMBANGAN PERMUKIMAN DAN PERBATASAN PAPUAPELAKSANAAN KEGIATAN PENGEMBANGAN KAWASAN PERMUKIMAN PERDESAANAlamat : Jln. Sumatera Nmr. !" D# I$ Tel%. &'()*+ ""'!,' - a/. &'()*+ ""'!,' Ja0a%ura

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 6/31

BAB III. INSTRUKSI KEPADA PESERTA IKP

A. UMUM. Pan,,a

P"nga*aan *anL,ng'2P""r+aan

1.1 P++ P' -'-%+ $''%*& LDK &'%&%&$'*$- ' '$'0J- K#-%*-+ $' '-'0.

1.2 N& $' *+$% '$'0+'%$ *& LDK.

%. S'm$"r Dana P'$'0 ++ +/+:+ ' -'-%+ $''% *& LDK.

5. P"#"raK'al,6,a#,

3.1 D*& * '-'0 $ % -'&'*$%$ $'&+0 /+$ ''0%- -+#* &%% -+&$ '-'0 0%- &'&+*+$+ '0+$'0 -& #'0-+6$'&+0 :&'&% '0-'-' $'&+0 '0%- : &'?$+*+ $'&+0'0-'/%.

3.2 U%$ +*+ '$'0 + /? R

1... (-'%*% &+*+0 0%+) &$ $'&+0 0%- '0+0+0+ '0%- -+#*.

7. LaranganKor'2#,8Kol'#,8 *anN"2o,#m"(KKN) #"raP"n,2'an

4.1 P'-'0 +$ : '0$+ '' ++ /'0$'?+/ %%$&'&%+ '+$ ' '+$ &'*$%$ +$ -'/+/'0+$%8. /'0%- &'&'0%+ #

P++ P' *& /'%$

0 % %%$ &'&'%+$'++ '-'0 :/'0' ' D#$%&'K%*+,+$-+ 6% '0%0'0%<%;

/. &'*$%$ '0-'$#$#* ''-'0 *+ %%$ &'%0 -+*$%*+,+$-+ -'+&'%0+6&'&/6&'&'0$'+* &'+$'0-+ : -' 6%

&'0%+$ +$ *+;. &'&/% 6% &':&+$

#$%&' 6% $''0 *+: +$ /'0 %%$ &'&'%+'0-:0 *& D#$%&'K%*+,+$-+.

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 7/31

4.2 P'-'0 : '0/%$+ &'*$%$+$ -'/+& +&$-%*& $ 4.1 + - +$'$-$-+<-$-+ -'/+ /'0+$%8. -$-+ &++-0+, -''0+

+%%0$ 0+ 0#-'- $%*+,+$-+% '&/* $'*%*%-$%*+,+$-+;

/. -$-+ '%& *& D,0 >+&;

. % -'0 '0; 6%. '*#0 -'0 + $'

+$ /'0?'.

4.3 P'' -$-+ +*#0$ #*'P++ P' $' PA6KPA.

!. LaranganP"r"nanganK"2"n,ngan

5.1 L0 '0' $''++%%$ %%$ &'&+ '0+*$% +$ +$ $#-+-' 0+ 0+$ *& &'*$-$ %-,%-+ '0:. O*' $0' +%: /'0-$% +$ /#*'&'&+*+$+6&'*$%$ '0 %'0,+*+-+.

5.3 P'0 -'/+& +&$-%

$ 5.1 +- 0 *+&'*+%+8. -'#0 # D+0'$-+ %

D'? K#&+-0+- -%% /%- +*0 &'0$ -'/+# D+0'$-+ % D'?K#&+-0+- B U-*+: : &'+ '-'0 S'*'$-+ $' '$'0 :-&;

/. *& P'$'0 K#-0%$-+$#-%* '0' /'0+$-'/+ '*$- '$'0 %$#-%* '?- '$'0: +0'$: $'%*+*& '*$- K#0$T'0+& J+ (%0 $': #0) K#0$ P' P'$'0T'0+'0-+.

. '%0%- $#'0-+ '?+ *&-%% K6L6D6I % $'0%- BUMN6BUMD: &'+$%+ P'B06J- /'0-+ ''0%- *+: +*0&'0$ -'/+ #P++ P' % '/: /'0?' &''%$'&' S'*'$-+.

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 8/31

5.4 T'0,+*+-+ -'/+& +&$-% $ 5.1 + - *$''0$+ %/% /+$ 0 '-'0 &%% 0 '-'0' PPK 6% P++

P' 0 *+ &'*+%+8. %/% $'*%0 $0''0$?+ $'%0% -&+' '0 $'% /+$ -'0#0+#* &%% ='0+$*;

/. PPK 6% P++ P'/+$ *-% &%% +$*-% &''*+$ %&'*$ '0%- '-'0;

. %/% 0 2 (%)'0%- : +$'*+$ /+$

*-% &%% +$ *-%#*' +$ : -& :+% *'/+0+ 5 (*+& %*% '0-'0%-)'&' -& 6% -*-% '%0%-: -&.

5.5 P'?+ K6L6D6I +*0 &'+'-'0 $'%*+ %+ + *%0 %K6L6D6I.

0. Sa'Do'm"nK'al,6,a#,,a2 P"#"ra

@.1 S'+ '-'0 /+$ - & -'+0+

&%% -'/+ # $'&+0: +'0/#*'$ %%$&':&+$ -% D#$%&'K%*+,+$-+.

@.2 S'+ '-'0 : '0&-%$ *&$'&+0 +*0 &'+ '-'0/+$ -'0 -'+0+ &%% #$'&+0 : *+ $''$'0 : -&.

B. DOKUMEN KUALIFIKASI

9. I#, Do'm"nK'al,6,a#,

7.1 P'-'0 /'0$'?+/ &'&'0+$-$'-'*%0% +-+ D#$%&' K%*+,+$-+.K'**+ &':&+$ $''0: +-:0$ *& D#$%&'K%*+,+$-+ -''%: &'0%$0'-+$# '-'0.

7.2 P'-'0 &'&+ ''*--'0 '0%*+- &''+ +-+ D#$%&'K%*+,+$-+.

. Ba-a#aDo'm"nK'al,6,a#,

D#$%&' K%*+,+$-+ /'-'0 -'*%0%$#0'-#'-+ '0%*+- *& 0#-'-$%*+,+$-+ &'%$ B-I#'-+.

;. P"r'$a-an S'/'*%& /- $+0 ?$%

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 9/31

Do'm"nK'al,6,a#,

':&+ D#$%&' K%*+,+$-+P++ P' &'%/D#$%&' K%*+,+$-+ '&''$ A'%&.

  S'+ A'%& : +'$&'0%$ /+ : +$'0+-$ 0+ D#$%&' K%*+,+$-+ +-&+$ $' -'&%'-'0.

 A/+* '%& D#$%&'K%*+,+$-+ P++ P' &'%%0$ /- $+0 ?$%':&+ D#$%&' K%*+,+$-+ +%$ *& '%& :

&'%&$ '%%0 /-$+0 ?$% ':&+ D#$%&'K%*+,+$-+.

&. B"rla'n4aK'al,6,a#,

K%*+,+$-+ ++ : /'0*$% %%$$' '$'0 : '0%& *&LDK.

. B,a4aK'al,6,a#,

11.1 P'-'0 -''%: &'%/+: %%$ &'+$%+ $%*+,+$-+ ++.

11.2 P++ P' +$ /'0% ?/ - $'0%+ % :+% #*' '-'0.

<.P"n4,a2an Do'm"n K'al,6,a#,

%. P"ng,#,anDo'm"nK'al,6,a#,

12.1 P'-'0 /'0$'?+/ %%$&'*'$+ P$ I'0+- &'+-+ F#0&%*+0 I-+ K%*+,+$-+

12.2 P$ I'0+- F#0&%*+0 I-+K%*+,+$-+ 0%- ++ #*'8. +0'$%0 %&6+&+

'0%-;b. ''0+& $%- 0+ +0'$%0 

%&6+&+ '0%- :& ''0+& $%-:'0%& *& $' '+0+% '0%/: (+:$' -%0 $%-);

c. $'* / '0%- :+$ #*' $#0 %- :+/%$+$ ' #$%&'#'+$; %

d. '/ : &'%0% '0+$'0 -& /'0$ &'?$+*+'0%- : /'$'0 -&.

5. B"n'Do'm"n

D#$%&' K%*+,+$-+ +-&+$-'/:$ 3 (+) 0$ : '0+0+

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 10/31

K'al,6,a#, 0+8 #$%&' -*+ 1 (-%) 0$ -*+: 2 (%) 0$ -'0++ ASLI REKAMAN. J+$'0 $'+$-'-%+ 0#$%&' -*+ 0'$& &$

#$%&' -*+ : /'0*$%.

D.P"ma#'an Do'm"n K'al,6,a#,

7. P"ma#'anDo'm"nK'al,6,a#,

14.1 D#$%&' K%*+,+$-+ +&-%$$*& -&%* '%% +%*+-Do'm"n K'al,6,a#, &$' '$'0 & *&'-'0 -'0 +-&+$ $'P++ P' ' *&: +'%$ *& LDK.

14.2 P'-'0 &':&+$ *-%D#$%&' K%*+,+$-+ $' P++P' -'-%+ ?* :+'$ *& LDK.

14.3 P'-'0 &':&+$D#$%&' K%*+,+$-+ &'**%+ #-6-'+0+& ' $''% -%+'0+& P++ P' -'-%+

 ?* : +'$ *& LDK.

14.4 D*& * D#$%&' K%*+,+$-++-&+$ &'**%+ #-6-'+0+& &$ -&%* '%%+&-%$$ $' *& 1 (-%) -&%**%0 : &'%&$ & $''$'0 *& P++P'.

!. Do'm"nK'al,6,a#,T"rlam$a

15.1 S'+ D#$%&' K%*+,+$-+ :+'0+& #*' P++ P'-''* /- $+0 ?$%':&+ D#$%&' K%*+,+$-+&$ D#$%&' K%*+,+$-+ :'0*&/ '0-'/% $ +#*$.

P++ P' -''0&'&/'0+%$ $' '-'0 :/'0-$% %%$ &'&/+*$'&/*+ -'*%0% D#$%&' K%*+,+$-++-'0+ ' /%$+ -'0 '0+&.

15.2 D*& * D#$%&' K%*+,+$-++-&+$ &'**%+ #-6-'+0+& &$ -'* 0+-+$#$''0*&/ $'0%-$#$%&' &'+ 0+-+$# '-'0.

E. P"r#4araan P"#"ra K'al,6,a#,

0. P"r#4araan P'0-:0 K%*+,+$-+ *

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 11/31

K'al,6,a#, -'/+ /'0+$%81. ,#0&%*+0 +-+ $%*+,+$-+

++ #*'8. +0'$%0 %&6+&+

'0%-;

/. ''0+& $%- 0+ +0'$%0 %&6+&+ '0%-: & ''0+& $%-:'0%& *& $' '+0+% '0%/: (+:$' -%0 $%-);

. $'* / '0%- :+$ #*' $#0 %- :+/%$+$ ' #$%&'#'+$; %

. '/ : &'%0% '0+

$'0 -& /'0$ &'?$+*+'0%- : /'$'0 -&;

2. &'&+*+$+ -%0 ++ %- -'-%+' '0%0 '0%<% -'-%+ : +'%$*& LDK;

3. &':&+$'0:6'$% '0%*+-/? / %- :/'0-$% &'&':

+$ *& '?-'+* +$ +*+ $'+%-: +$ -' +'+$6% +0'$-+ : /'0+$%%$ - & '0%-+$ -' *& &'*+-$-+ +;

4. -* -% 6% -'&%'%0%- / %-:+$ &-%$ *& ,0 +&;

5. &'&+*+$+ NPCP '*&'&'%+ $'?+/ '0$% $ '0$+0 (SPT T%)-'0 &'&+*+$+ *#0 /%* PPP-* 21 PP P-* 23 (/+* 0-$-+) PP P-* 256P-* 29 PPN (/+ P'%- K'P$) *+ $%0 3 (+) /%*'0$+0 *& % /'0*.P'-'0 &'+'0-:0 ++ '&':&+$ S%0 K''0F+-$* (SKF);

@. &'&'0#*' *+ -'+$+ 1 (-%)'$'0 -'/+ ':'+ -$#-%*-+ *& $%0% ?$% 4('&) % '0$+0 /+$ +*+$% '&'0+ &%%-?- '0&-%$ '*&-%/$#0$ $'%*+ ':'+ -

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 12/31

$#-%*-+ : /0% /'0+0+$%0 0+ 3 (+) %;

7. &'&+*+$+ $'&&% -%//+ '$'0 : -'-%+;

. &'&+*+$+ $'&&% &':'+$

,-+*+- '0* -'0 '0-#+*: +'0*%$ %%$ '*$-'$'0 -'-%+ : +'%$*& LDK;

9. &':&+$ ,0 '0#*''$'0 : -' +$'0$;

1. *& * '-'0 $&'*$%$ $'&+08. ?+/ &'&%:+ '0+

K'0 S& O'0-+6$'&+0: &'&% '0-'-'

$'&+0 '0%- :&'?$+*+ $'&+0 '0-'/%;/. '=*%-+ '0-:0 $%*+,+$-+

%0%, ) -&+ '%0%, +) +*$%$ '0-'*%0% '-'0 : '0/%*& K'0 S&O'0-+6$'&+0;

. /+* $ +'$ -'/+'&' &$ '0+K'0 S& O'0-+6$'&+0

0%- +-$ #*' #0+-.11. &'&+*+$+ -'0+,+$ &'&' &%%ISO % '0-:0 *+ -''0+'0* $%-%- ' *+-'-+*+- : +'0*%$ %'*& '0'% /+*+-:0$.

9. P"r#4araanT"n,#K'al,6,a#,

17.1 P'*& '0%- '$'0 : -''+- $#&*'$-+- : -'0 '/#/# -'-%+ ' : +'$*& LDK.

17.2 K''&+*+$ ' *+ ''0&-%$ %-%0' $#&+-0+-6+0'$-+: /'0'*& '$'0: -''+- $#&*'$-+- :-'0 ' /#/# -'-%+ ': +'$ *& LDK.

17.3 D*& * '$'0 $#&*'$- :+'0-:0$ -'/+& -* 1@$ 11 *& $0+'0+ '+*+0%- +'0+%$ '0-:0&'&+*+$+ -'0+,+$ &'&' &%%ISO % '0-:0 *+ -''0+'0* $%-%- ' *+ -'-+*+-: +'0*%$ % '*&'0'% %%$ '$'0 $#&*'$-

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 13/31

' /#/# '0'% :/'-0: &'%0+ /#/#'*& '0%- +'$ *& LDK.

F. E=al'a#, K'al,6,a#,

9. K"ra-a#,aanPro#"#

I,#0&-+ : /'0$+ ''=*%-+ $%*+,+$-+ +$ /#*'+%$$ $' 0 '-'0 %+$ *+ + -+* $%*+,+$-++%&%&$.

9. E=al'a#,K'al,6,a#,

17.1 P$ I'0+- '* ++-+ ++ #*' '-'0 -'/'*%&+*$%$ '=*%-+. A/+* +$

&'+ P$ I'0+--&+ ' /- ?$% :+'%$ &$ '=*%-+ +$+*%$.

17.2 E=*%-+ K%*+,+$-+ : /'0-0$F#0&%*+0 I-+ K%*+,+$-+ : '0+0+0+8. '+*+ P'0-:0 K%*+,+$-+

: +*$%$ ' S+-'&G%%0;

/. '=*%-+ P'0-:0 T'$+-K%*+,+$-+ -'-%+ : +'%$*& LDK : +*$%$ 'S+-'& N+*+ %%$ &'-+*$"*# D,0 P''$.

17.3 D< *& ,#0&%*+0 +-+$%*+,+$-+ +*'$+ -&+' /- $+0 '&-%$#$%&' $%*+,+$-+.

17.4 T "0 E=*%-+ K%*+,+$-++*$%$ -'-%+ ' B/ VIIID#$%&' K%*+,+$-+ ++.

. P"m$',anK'al,6,a#,

1.1 T'0 '-'0 : &-%$ *&"*# D,0 P''$ +*$%$'&/%$+ $%*+,+$-+.

1.2 P'&/%$+ $%*+,+$-+ +*$%$' 0 &'*+ $'-*+ #$%&' &'&+ -*+:.

1.3 P++ P' &'*$%$$*0+,+$-+ 6% ='0+,+$-+ $'''0/+ #$%&' /+* +'0*%$.

1.4 A/+* -+* '&/%$+ $%*+,+$-++'&%$ '&*-% &$'-'0 +%%0$ / %-

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 14/31

6% '%0%-: +&-%$$*& D,0 >+&.

G. Ha#,l K'al,6,a#,

;. P"n"a2anHa#,lK'al,6,a#,

19.1 S'&% '-'0 : *%*%- '&/%$+$%*+,+$-+ +&-%$$ #*' P++P' $' *& D,0 P''$(short list ) *+ $%0 5 (*+&) *+ /:$ 7 (%%) '-'0 0+,0 '-'0 : '* *%*%-'&/%$+ $%*+,+$-+ /'0-0$%0% '0/+$.

19.2 A/+* '-'0 : *%*%- '&/%$+$%*+,+$-+ $%0 0+ 5 (*+&) &$

-'*'$-+ +:$ *.

%&. P"ng'm'manHa#,lK'al,6,a#,

>-+* $%*+,+$-+ -''* +'$ #*'P++ P' +/'0+%$$' -'*%0% '-'0 +%&%&$ #*' P++ P'&'**%+ *& ???.%.#.+ '%&%& 0'-&+ %%$&-:0$.

%. Sangga-an 21.1 P'-'0 &':&+$

- '0%*+- $' P++P' *& ?$% 5 (*+&) 0+$'0 -''* '%&%& -+*$%*+,+$-+ +-'0+ /%$+ '0+:':+& ' '&/%-$' PPK PA6KPA I-'$#0J''0* K'&''0+ PU -'-%+ :'0%& *& LDK.

21.2 S +%$ #*' '-'0 /+$-'0 -'+0+<-'+0+ &%%/'0-&<-& ' '-'0 *+/+* '0+ ':+& 0#-'%0 &'*+%+8. ':+& '0 $''%

0#-'%0 : +%0 *&P'0% P0'-+' ++ :'* +'$ *& D#$%&'K%*+,+$-+;

/. 0'$:- '0'% -'+&'*+ '0+: '0-+%- : -'; 6%

. ':*% ?'?' #*'P++ P' 6%'/ : /'0?' *+:.

21.3 P++ P' ?+/ &'&/'0+$ ?/ '0%*+- - -'&%- -'*&/*&/: 5(*+&) 0+ $'0 -''* &''0+&

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 15/31

-%0 -.

21.4 A/+* - +:$ /'0 &$ P++ P' &':$-'*'$-+ *.

21.5 T+$ - /+ *&0#-'- 0$%*+,+$-+.

%%. K'al,6,a#,Ulang

22.1 A/+* %&* '-'0 : *%*%-$%*+,+$-+ $%0 0+ 5 (*+&) %%$S'*'$-+ U&%& % $%0 0+ 3 (+)%%$ S'*'$-+ S''0 &$+*$%$ '%&%& %*0$%*+,+$-+ %%$ &'0+ '-'0/0% -'*+ '-'0 : '* *%*%-

'+*+ $%*+,+$-+. P'-'0 :-% *%*%- '+*+ $%*+,+$-+ +$'0*% +*$%$ '+*+ $'&/*+$'%*+ '0%/ D#$%&'K%*+,+$-+.

22.2 J+$ -''* $%*+,+$-+ %* '0:'-'0 : *%*%- $%*+,+$-+ /'0%&*$%0 0+ 5 (*+&) %%$ S'*'$-+U&%& % $%0 0+ 3 (+) %%$S'*'$-+ S''0 &$ 0#-'-

-'*'$-+ +*%$.

%5. Un*angan"2a*aP"#"raK'al,6,a#,4ang L'l'#

J+$ +$ - %- +#*$ &$ '-'0 :&-%$ *& D,0 P''$ +%%%$ &'&/+* D#$%&' P'&+*+%%$ &'&-%$$ '?0.

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 16/31

BAB I>. LEMBAR DATA KUALIFIKASI (LDK)

A. Pan,,aP"nga*aan *anL,ng'2P""r+aan

1. N& P++ P' 8 Satker Pengembangan

Kawasan Permukiman

-an Perbatasan Papua A*& P++ P' 8 Jl$ Sumatera No$ %. 

Dok$ / Ja0apura A*& C'/-+' 8 www$pu$go$i- 

2. N& P$' P'$'0 8 Pengawasan

Pembangunan Jalan

Poros Desa Kawasan

SP Distrik Mimika

Kabupaten Mimika

3. L+$% P'$'0 8 Pengawasan

Pembangunan JalanPoros Kawasan SP

Distrik Mimika Kab$

Mimika

B. S'm$"r Dana P' ++ +/+:+ 0+ -%&/'0 '8 APBN

T% A0 212

<. B"rla'n4aK'al,6,a#,

K%*+,+$-+ ++ : /'0*$% %%$ $' '$'0

Pengawasan Pembangunan Jalan Poros Desa Kawasan

SP Distrik Mimika Kabupaten Mimika

D. P"n4am2a,anDo'm"nK'al,6,a#,

>0+ 8 S'*-T* 8 27 D'-'&/'0 211P%$%* 8 9. C+. -.. 15. C+.T'& 8 J*. S%&'0 N#. 15 D#$. IV J:%0.

E. P"r#4araanK'al,6,a#,

1. P'-'0 $%*+,+$-+ : /'0/ %- 0%- &'&+*+$+

-%0 ++ %- J- I-'$-+.

2. &'&+*+$+ ,-+*+- 6 '0* 6 '0-#+* %%$ &'*$-$'$'0 - $#-%*-+ ++ :+%8 K#&%'0 P0+'0 A3

"&'0 D++* GPS.

F. P"r#4araanT"n,#K'al,6,a#,

1. &'&+*+$+ '*& '$'0 J- I-'$-+

' #* /#/# '+*+ -'/'-0 @ .

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 17/31

2. &'&+*+$+ T' A*+ T' ' $%*+,+$-+ $'*+

B+ S++* A0-+'$%0 L+$% '

'*& &++&* 1 (-%) %  ' #* /#/#

'+*+ -'/'-0 4 ;

3. A/+* +'0-:0$ '$'0 $#&*'$- &$ 0%-

&'&+*+$+ -'0+,+$ &'&' &%% ISO % '0-:0

*+ -''0+ '0* $%-%- ' *+ -'-+*+- :

+'0*%$ % '*& '0'% %%$ '$'0

$#&*'$- ' /#/# : /'-0: &'%0+

/#/# '*& '0%- -'/'-0

G. Sangga- T'&/%- - +-&+$ $'8

1. PPK . P''&/ K?- P'0&%$+&

  P'0'- P%

2. KPA . S$'0 P''&/ K?- P'0&%$+&

P'0/- P%

3. -.

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 18/31

BAB >. SURAT PERJANJIAN KEMITRAAN

BENTUK SURAT PERJANJIAN KEMITRAAN 1 KERJA SAMA OPERASI (KSO)

SURAT PERJANJIAN KEMITRAAN 1

KERJA SAMA OPERASI (KSO)

MENIMBANG :

BA1WA(

S'%/% ' -'*'$-+ '$'0 ..................... : '&/%$ '?0:

$ +*$%$ + .................. * .......... 2...... &$ 8

.................................. [nama peserta 1],

.................................. [nama peserta 2],

..................................[nama peserta 3],

...................................[dan seterusna]!

/'0&$-% %%$ &'+$%+ '*'* '*$- $#0$ -'0 /'0-&<-&

*& /'%$ $'&+06K'0 S& O'0-+ (KSO).

MEN?ETUJUI DAN MEMUTUSKAN :

BA1WA(

1. S'0 /'0-&<-&8

1. M'&/'%$ $'&+06KSO ' & $'&+06KSO * ............2. M'%%$ ................... [nama peserta 1] -'/+ '0%- %& "leading #irm$

%%$ $'&+06KSO &'?$+*+ -'0 /'0+$ %%$ - &

$'&+06KSO.

3. M':'%%+ /+* +%%$ -'/+ '&' ?+/ /'0% ?/ /+$

-'0 /'0-&<-& % &-+<&-+ - -'&% $'?+/ -'-%+

$''% #$%&' $#0$.

2. K'+$%-'0 "sharing$ -'+ '0%- *& $'&+06KSO *8

P'-'0 1 ............ (....................'0-') 0+ &#* 6% ' *+

P'-'0 2 ............ (....................'0-') 0+ &#* 6% ' *+P'-'0 3 ............ (....................'0-') 0+ &#* 6% ' *+

................ -''0%-:.

3. M-+<&-+ '-'0 # $'&+06KSO $ &'&/+* /+ -'-%+

sharing '0-'/% /%+0 2. *& * ''*%0 $'%% $'0%+ 0+

$'&+06KSO. P'&/+ sharing *& $'&+06KSO ++ +$ $ +%/ /+$

"ONTO>

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 19/31

-'*& &- '?0 &%% -' &- $#0$ $'%*+ '

'0-'%% '0%*+- '0*'/+ %*% 0+ P++ ' % P'/ P'&/%

K#&+&' (PPK) '0-'%% /'0-& -'0 '0%*+- 0+ &-+&-+

# $'&+06KSO. T'0*'- 0+ sharing : +'$ +- &-+<

&-+ # $'&+06KSO $ &'*$%$ '?- '% '0

-'&% -'$ '*$- 0+ '0+ ++ '0&-%$ $ %%$ &'&'0+$-$'% '0+ '&/'*+ '0+& ,0 '0* ' $'0

'0+ -%/$#0$ -%0<&':%0 '*'$- *+<*+.

4. C'?' &'+ %%$ - & $'&+06KSO +/'0+$

$' ................... [nama wakil peserta ang diberi kuasa] *& $'%%$:

-'/+ '&+&+6+0'$%0 %& '0%- ..................[nama   peserta 1] 

/'0-0$ '0-'%% '0%*+-) 0+ .............[nama peserta 2]  .......................

[nama peserta 3] .....................[dan seterusna] -'%/% ' -%/--+

-'&% $''% *& -'&% #$%&' : $ + +.

5. P'0+ ++ $ /'0*$% -'$ * ++.

@. P'0+ ++ -'0 ##&+- &'+ /* +$ /'0*$% *+ /+* -'*'$-+ +$

+&'$ #*' '0%- $'&+06KSO.

7. P'0+ ++ +/% *& 0$ .............. (....................) : &-+<&-+

&'&%:+ $'$% %$%& : -&.

DENGAN KESEPAKATAN INI -'&% # $'&+06KSO &'&/%/%$

+ .............. 0+ ............... * ........... /%* ............. % ......................

  P':'+ 1 P':'+ 2 P':'+ 3

  (.............................) (............................) (............................)

-''0%-:

(...............................)

D+-$ #*' NOTARIS)

(...............................)

) sebelum menandatangani dokumen%dokumen atas nama kemitraan harus

mendapatkan persetu&uan tertulis dari anggota kemitraan'KS(!

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 20/31

) dapat disahkan setelah kemitraan ditun&uk sebagai pelaksana peker&aan dengan

ketentuan prosentase kemitraan dan perusahaan ang mewakili kemitraan tersebut 

tidak berubah!

BAB >I. PAKTA INTEGRITAS

[)ontoh Pakta *ntegritas +adan saha -anpa Kemitraan] 

PAKTA INTEGRITAS

S: : /'0 + /? ++8

N& 8 .................... [nama wakil sah badan usaha] 

J/ 8 ....................

B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.................... - & 8 …………………………………[  pilih ang sesuai dan .antumkan

nama ] 

*& 0$ ' .................... .................... [isi sesuai dengan

Satuan Ker&a di lingkungan Kementerian P] ' ++ &':$ /?8

1. +$ $ &'*$%$ 0$'$ K#0%-+ K#*%-+ N'#+-&' (KKN);

2. $ &'*#0$ $' +$ : /'0?+/6/'0?' /+* &''%+

++$-+ KKN *& 0#-'- ' ++;

3. $ &'+$%+ 0#-'- ' -'0 /'0-+ 0-0 0#,'-+#*

%%$ &'&/'0+$ -+* $'0 '0/+$ -'-%+ $''% '0%0 '0%<

%;

4. /+* &'*0 *<* : +:$ *& PAKTA INTEGRITAS ++

/'0-'+ &''0+& -$-+ &++-0+, &''0+& -$-+ '%& *&

D,0 >+& +% -'0 '0 6% +*#0$ -'0 +.

.................... [tempat]  ............[tanggal] .................... [bulan] 2... [tahun] 

[/ama Penedia] 

[tanda tangan]  

[nama lengkap] 

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 21/31

[)ontoh Pakta *ntegritas +adan saha Dengan Kemitraan] 

PAKTA INTEGRITAS

K&+ : /'0 + /? ++8

1. N& 8 .................... [nama wakil sah badan usaha] 

J/ 8 ....................

B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.....................................

- & 8 ..................................... [pilih ang sesuai dan .antumkan

nama] 

2. N& 8 .................... [nama wakil sah badan usaha] 

J/ 8 ....................

B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.....................................

- & 8 ..................................... [pilih ang sesuai dan .antumkan

nama] 

3. ......[dan seterusna, diisi sesuai dengan &umlah anggota kemitraan] 

*& 0$ ' .................... .................... [isi sesuai dengan

Satuan Ker&a di lingkungan Kementerian P] ' ++ &':$ /?8

1. +$ $ &'*$%$ 0$'$ K#0%-+ K#*%-+ N'#+-&' (KKN);

2. $ &'*#0$ $' +$ : /'0?+/6/'0?' /+* &''%+

++$-+ KKN *& 0#-'- ' ++;

3. $ &'+$%+ 0#-'- ' -'0 /'0-+ 0-0 0#,'-+#*

%%$ &'&/'0+$ -+* $'0 '0/+$ -'-%+ $''% '0%0 '0%<%;

4. /+* &'*0 *<* : +:$ *& PAKTA INTEGRITAS ++

/'0-'+ &''0+& -$-+ &++-0+, &''0+& -$-+ '%& *&

D,0 >+& +% -'0 '0 6% +*#0$ -'0 +.

.................... [tempat]  ............[tanggal] .................... [bulan] 2... [tahun] 

[/ama Penedia] 

[tanda tangan]  

[nama lengkap] 

[/ama Penedia] 

[tanda tangan]  

[nama lengkap] 

[/ama Penedia] 

[tanda tangan]  

[nama lengkap] 

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 22/31

BAB >II. FORMULIR ISIAN KUALIFIKASI

S: : /'0 + /? ++8

N& 8 .................... [nama wakil sah badan usaha] 

J/ 8 ....................

B'0+$ %%$ 8 PT6"V6F+0&6K#'0-+6K'&+0.....................................

- & 8 ..................................... [pilih ang sesuai dan .antumkan

nama] 

 A*& 8 ...................................

T'*'#6FH 8 .....................................

E&+* 8 ......................................

&':$ ' -'-%%: /?8

1. -: -'0 %$%& &'&%:+ $-+- &'+ $#0$

/'0-0$ S%0 .................... [sesuai akte  pendirian'perubahanna'surat 

kuasa, disebutkan se.ara &elas nomor   dan tanggal akte pendirian'perubahan'surat kuasa! Jika Kemitraan  maka Surat dimaksud 

adalah Per&an&ian Kemitraan!] ;

2. -: /%$ -'/+ '?+ K6L6D6I [bagi pegawai K'0'D'* ang sedang .uti 

diluar tanggungan K'0'D'* ditulis sebagai berikut Saa merupakan pegawai 

K'0'D'* ang sedang .uti diluar tanggungan K'0'D'*] ;

3. -: +$ -' &'*+ -$-+ +;

4. -: +$ -' +$ $ '0*+/ '0' $''+ '

0 +$ : '0$+ *-% &%% +$ *-% *& 0#-'-

' ++;

5. / %- : -: ?$+*+ +$ &-%$ *& D,0 >+& +$ *&

'?- '+* +$ +*+ $'+ %-: +$ -'

+'+$;

@. -* -% 6% -'&% '%0%- / %- : -: ?$+*+ +$

&-%$ *& D,0 >+&

7. < -:6/ %- : -: ?$+*+ * -'/+ /'0+$%8

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 23/31

A. Daa A*m,n,#ra#,

1.N& (PT6"V6F+0&6K#'0-+6K'&+0) 8

………………………………………

2. S%-8

 P%- "/

  K'&+0

3.

 A*& 8 …………………………………..N#.T'* 8 …………………………………..N#. FH 8 ………………………………….E&+*

8……………………………………

4.

 A*&8

…………………………………..N#.T'* 8 …………………………………..N#. FH 8 ……………………………………E&+*

8……………………………………

B. I@,n U#a-a

1. S%0 I+ U- ............ 8 N#. ………………. T* ……………

2. M- /'0*$% ++ %- 8 …………………………

3. I--+ '&/'0+ ++%-

8 …………………………

<. I@,n La,nn4a (a2a$,la *,2"r#4araan)

1. S%0 I+ U- ............ 8 N#. ………………. T* ……………

2. M- /'0*$% ++ %- 8 …………………………

3. I--+ '&/'0+ ++%-

8 …………………………

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 24/31

D. Lan*a#an H''m P"n*,r,an Ba*an U#a-a1K"m,raan

1.  A$' P'+0+ PT6"V6F+0&6K#'0-+6K'&+0

. N#. A$' 8 ………………………../. T* 8 ………………………... N& N#0+- 8 ………………………..

2. A$' P'0%/ T'0$+0 

. N#. A$' 8 …………………………

/. T* 8 …………………………. N& N#0+- 8 …………………………

E. P"ng'r'#

. Kom,#ar,# 'n' P"r#"roan T"r$aa# (PT)

No. Nama No. KTPJa$aan *alam Ba*an

U#a-a

%. D,r"#,1P"ng'r'# Ba*an U#a-a1K"m,raan

No. Nama No. KTPJa$aan *alam Ba*an

U#a-a

5. Kom,#ar,# Ba*an U#a-a

No. Nama No. KTPJa$aan *alam Ba*an

U#a-a

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 25/31

F. Daa K"'angan

. S'#'nan K"2"m,l,an Sa-am ('n' PT)1S'#'nan P"#"ro ('n'<>1F,rma)1S'#'nan K"m,raan

No. Nama No. KTP Alama Pr"#"na#"

%. Pa+a

. N#&#0 P#$#$ C+/ P$ 8 ……………………/. B%$+ L#0 P$ T%

'0$+0 

8 N#. ………………………..T* …………………..

. B%$+ L#0 /%* (+

/%* '0$+0)

8

1) PP P-* 21 8 N#. ………………………..T* …………………..

2) PP P-* 23 (/+*

0-$-+)

8 N#. ………………………..T* …………………..

3) PP P-* 256P-* 29 8 N#. ………………………..

T* …………………..4) PPN 8 N#. ………………………..

T* …………………..

G. Daa P"r#onal,a (T"naga a-l, "a2 $a*an '#a-a1"m,raan)

No. NamaTgl1$ln1T-n

La-,r T,nga

P"n*,*,an

Ja$aan*alam

2""r+aan

P"ngalamanK"r+a (a-'n)

Pro6"#,1K"a-l,an

Ta-'nS"r,6,a1I+a@a-

% 5 7 ! 0 9

H. Daa P"ngalaman P"r'#a-aan & (#"2'l'-) a-'n "ra-,r 

No.NamaPa"

P""r+aan

B,*ang1S'$

B,*angP""r+aan

Loa#,

P"m$"r,T'ga#1P"+a$a

P"m$'a Kom,m"nKonra

Tanggal S"l"#a,M"n'r'

NamaAlama1T"l"2on

No 1Tanggal

N,la, KonraBA

S"ra-T"r,ma

1 2 3 4 5 @ 7 9 1

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 26/31

I. Daa P""r+aan 4ang #"*ang *,la#anaan

No.NamaPa"

P""r+aan

B,*ang1S'$B,*ang

P""r+aan

Loa#,

P"m$"r,T'ga#1P"+a$a

P"m$'aKom,m"n

Konra

Tanggal S"l"#a,

M"n'r'

NamaAlama1T"l"2on

No 1Tanggal

N,la,Konra

(r"nana)

Pr"#a#,K"r+a ()

1 2 3 4 5 @ 7 9 1

J. Daa Fa#,l,a#1P"ralaan1P"rl"nga2an 4ang m"n*''ng[.antumkan &ika disaratkan oleh Panitia Pengadaan] 

N#.J'+-

F-+*+-6P'0*6P'0*'$

J%&*

K-+-%

output  -

++

M'0$+'

T%'&/%

K#+-+()

L#$-+S'$0

B%$+K''&+*+$)

1 2 3 4 5 @ 7 9

) B%$+</%$+ -%0 $''&+*+$ 0%- +%%$$ ?$% +'0*%$

D'&+$+ '0: ++ -: /% ' -'/'0: '% 0- %

 ?/. J+$ +$'&%+ 0+ +'&%+ /? 6#$%&' : -: -&+$

+$ /'0 % '&*-% &$ -: / %- : -: ?$+*+

/'0-'+ +$'$ -$-+ /'0% -$-+ &++-0+, -$-+ '%&

*& D,0 >+& % -'0 '0 6% '*#0 -'0 +

$' +$ /'0?' -'-%+ ' $''% '0%<%.

.................... [tempat]  ....... [tanggal] 

................ [bulan] 2 ..... [tahun] 

PT6"V6F+0&6K#'0-+6K'&+0

.................... [pilih ang sesuai dan

.antumkan nama] 

[rekatkan meterai p 4!555,% dan tanda

tangan] 

(nama lengkap wakil sah badan

usaha'kemitraan)

[&abatan pada badan usaha'kemitraan

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 27/31

BAB >III. PETUNJUK PENGISIAN FORMULIR ISIANKUALIFIKASI

A. A*m,n,#ra#,2. D++-+ ' & / %- '-'06$'&+0.

3. P+*+ -%- / %- (P%-6"/6K'&+0). U%$ : /%$

P%-6"/6K'&+0 0 &'+-+ -%- P%-.

4. D++-+ ' *& #&#0 '*'# #&#0 ,$-+&+*+ e%mail /

%- '-'06$'&+0 : +%/%+.

5. D++-+ ' *& #&#0 '*'# #&#0 ,$-+&+*+ e%mail $#0 

%- : +%/%+ : ++-+ /+* '-'0   /'0-%- $#0 

/.

B. I@,n U#a-a

 A0 -'/'*%& &'+-+ +-+$ ++ %- +&$-% * : +&+*+$+

#*' / %- : &'+$%+ $%*+,+$-+.

1. D++-+ ' '+- -%0 ++ %- #&#0 * ''0/+:.

2. D++-+ ' &- /'0*$% ++ %-.

3. D++-+ ' & +--+ ''0/+ -%0 ++ %-.

<. I@,n la,nn4a (a2a$,la *,2"r#4araan)

 A0 -'/'*%& &'+-+ +-+$ ++ *+: +&$-% * : +&+*+$+

#*' / %- : &'+$%+ $%*+,+$-+.1. D++-+ ' '+- -%0 ++ #&#0 * ''0/+:.

2. D++-+ ' &- /'0*$% ++.

3. D++-+ ' & +--+ ''0/+ -%0 ++.

D. Lan*a#an H''m P"n*,r,an Ba*an U#a-a1K"m,raan

1. D++-+ ' #&#0 * & N#0+- ''0/+ $' '+0+

/ %-6$'&+0.

2. D++-+ ' #&#0 * & N#0+- ''0/+ $' '0%/

'0$+0 / %-6$'&+0 /+* .

E. P"ng'r'#

1. D++-+ ' & #&#0 KTP / *& / %- /+*

/'0/'%$ P'0-'0# T'0/-.

2. D++-+ ' & #&#0 KTP / *& / %-6$'&+0.

3. D++-+ ' & #&#0 KTP / *& / %-.

F. Daa K"'angan

1. D++-+ ' & #&#0 KTP *& '&+*+$ -&6'-'0#6#

$'&+0 '0-'-' $''&+*+$ -&6'-'0#6$'&+0.

2. P$

. D++-+ NPCP / %-.

/. D++-+ #&#0 * /%$+ L#0 P$ T% '0$+0 /'0% SPT

T%.

. D++-+ #&#0 * /%$+ *#0 /%* (+ /%* '0$+0)

/'0% SPT M-8

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 28/31

1) PP P-* 21.

2) PP P-* 23.

3) PP P-* 256P-* 29.

4) PPN.

P'0-:0 '&'% $'?+/ $ % '0$+0 ' ':&+

SPT T% SPT M- ++ #*' P':'+ B06J- '

':&+ S%0 K''0 F+-$* (SKF) : +$'*%0$ #*' K#0 

P'*: P$

G. Daa P"r#onal,a

1. D++-+ #&#0 %0%.

2. D++-+ ' & ' *+ ' : +&+*+$+ #*' /

%-6$'&+0.

3. D++-+ *6/%*6% *+0.

4. D++-+ +$ '++$ :+% -0 % - -0.5. D++-+ / *& '$'0 : '0 +*$-$.

@. D++-+ *& '*& $'0 *& -% %.

7. D++-+ 0#,'-+6$'*+ -'-%+ ' -'0+,+$ $'*+ : +&+*+$+.

. D++-+ % ''0/+ -'0+,+$6+ 0+ -'+ ' *+ ' :

+'0*%$.

H. Daa P"ngalaman P"r'#a-aan

1. D++-+ #&#0 %0%.

2. D++-+ ' & $' '$'0 : '0 +*$-$.

3. D++-+ /+6-%//+ '$'0 : +'0-:0$.4. D++-+ *#$-+ '& '*$- '$'0.

5. D++-+ #&#06* $#0$.

@. D++-+ +*+ $#0$.

7. D++-+ * -'*'-+ $' '$'0 &'%0% $#0$.

. D++-+ * /'0+ 0 -'0 '0+& %%$ &-+<&-+ $'

'$'0 -'*& 1 (-'%*%) % '0$+0.

I. Daa P""r+aan 4ang #"*ang D,la#anaan

1. D++-+ #&#0 %0%.

2. D++-+ ' & $' '$'0.

3. D++-+ /+6-%//+ '$'0.

4. D++-+ *#$-+ '& '*$- '$'0.

5. D++-+ & I--+ 0+ P'&/'0+ T%-6P'/ P'&/% K#&+&'.

@. D++-+ *&6'*'# I--+ 0+ P'&/'0+ T%-6P'/ P'&/%

K#&+&'.

7. D++-+ #&#06* $#0$.

. D++-+ +*+ $#0$.

9. D++-+ '0-'-' 0#0'- &'%0% $#0$.

1.D++-+ '0-'-' 0'--+ $'0 '0$+0.

J. Daa Fa#,l,a#1P"ralaan1P"rl"nga2an

1. D++-+ #&#0 %0%.

2. D++-+ ' '+- ,-+*+-6'0*6'0*'$.

3. D++-+ %&*.

4. D++-+ $-+- % output : ++ - ++.

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 29/31

5. D++-+ &'0'$ +'.

@. D++-+ % '&/%.

7. D++-+ $#+-+ (*& '0-'-')

. D++-+ *#$-+ $'/'0 - ++.

9. D++-+ /%$+ $''&+*+$ (&+*+$ -'+0+6-'? /'*+6-'?) 0+ &-+&-+

,-+*+-6'0*6 '0*'$. B%$+ -%0 $''&+*+$ 0%-

+%%$$ ?$% P'&/%$+ K%*+,+$-+.

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 30/31

BAB IC. TATA <ARA E>ALUASI KUALIFIKASI

 A. S'/'*%& +*$%$ E=*%-+ K%*+,+$-+ &$ P++ P' &''*++

$ P$ I'0+- '* ++. A/+* P$ I'0+- +$++ &$ +$ +*$%$ '=*%-+ *'/+ *%. E=*%-+ K%*+,+$-+

+*$%$ /'0-0$ F#0&%*+0 I-+ K%*+,+$-+ : '0+0+ 0+8

1. '+*+ P'0-:0 K%*+,+$-+ : +*$%$ ' S+-'& G%%0;

2. '=*%-+ P'0-:0 T'$+- K%*+,+$-+ : +*$%$ ' S+-'& N+*+

%%$ &'-+*$ "*# D,0 P''$.

B. P'+*+ P'0-:0 K%*+,+$-+ 0%- &'&'%+ '0-:0 -'/+ /'0+$%8

1. F#0&%*+0 +-+ $%*+,+$-+ ++ #*'8

. +0'$%0 %&6+&+ '0%-;

/. ''0+& $%- 0+ +0'$%0 %&6+&+ '0%- : &

''0+& $%-: '0%& *& $' '+0+ % '0%/:

(+:$ ' -%0 $%-);

. $'* / '0%- : +$ #*' $#0 %- :

+/%$+$ ' #$%&' #'+$; %

. '/ : &'%0% '0+ $'0 -& /'0$ &'?$+*+ '0%-

: /'$'0 -&;

2. &'&+*+$+ -%0 ++ %- -'-%+ ' '0%0 '0%% (+

/+ '$'0 $#-0%$-+ % *+: -'-%+ : +/%%$);

3. &':&+$ '0:6'$% '0%*+- /? / %- :/'0-$% &'&': +$ *& '?- '+*

+$ +*+ $'+ %-: +$ -' +'+$ 6% +0'$-+

: /'0+$ %%$ - & '0%- +$ -' *&

&'*+ -$-+ +;

4. -* -% 6% -'&% '%0%- / %-: +$ &-%$

*& ,0 +&;

5. &'&+*+$+ NPCP '* &'&'%+ $'?+/ '0$ % $

'0$+0 (SPT T%) -'0 &'&+*+$+ *#0 /%* PP P-* 21 PP

P-* 23 (/+* 0-$-+) PP P-* 256P-* 29 PPN (/+

P'%- K' P$) *+ $%0 3 (+) /%* '0$+0 *& %/'0*. P'-'0 &'+ '0-:0 ++ ' &':&+$

S%0 K''0 F+-$* (SKF);

@. &'&'0#*' *+ -'+$+ 1 (-%) '$'0 -'/+ ':'+ -

$#-%*-+ *& $%0% ?$% 4 ('&) % '0$+0 /+$ + *+$%

'&'0+ &%% -?- '0&-%$ '*& -%/$#0$ $'%*+

':'+ - $#-%*-+ : /0% /'0+0+ $%0 0+ 3 (+) %;

7. &'&+*+$+ $'&&% -%/ /+ '$'0 : -'-%+;

. &'&+*+$+ $'&&% &':'+$ ,-+*+- '0* -'0 '0-#+*

: +'0*%$ %%$ '*$- '$'0;

9. &':&+$ ,0 '0#*' '$'0 : -' +$'0$;

1.*& * '-'0 $ &'*$%$ $'&+08

. ?+/ &'&%:+ '0+ K'0 S& O'0-+6$'&+0 :

&'&% '0-'-' $'&+0 '0%- : &'?$+*+

$'&+0 '0-'/%;

7/26/2019 dokumen kualifikasi pengawasan

http://slidepdf.com/reader/full/dokumen-kualifikasi-pengawasan 31/31

/. '=*%-+ '0-:0 $%*+,+$-+ %0%, ) -&+ ' %0%, +)

+*$%$ '0 -'*%0% '-'0 : '0/% *& K'0 S&

O'0-+6$'&+0;

. /+* $ +'$ -'/+ '&' &$ '0+ K'0

S& O'0-+6$'&+0 0%- +-$ #*' #0+-.

11. &'&+*+$+ -'0+,+$ &'&' &%% ISO % '0-:0 *+ -''0+

'0* $%-%- ' *+ -'-+*+- : +'0*%$ % '*&

'0'% /+* +-:0$.

". P'-'0 : &'&'%+ P'0-:0 K%*+,+$-+ +*%$ ' &'*$%$

E=*%-+ P'0-:0 T'$+- K%*+,+$-+.

D. A/+* +$ '-'0 % $%0 0+ 5 (*+&) '-'0 : &'&'%+

P'0-:0 K%*+,+$-+ &$ -'*'$-+ +:$ *.

E. E=*%-+ P'0-:0 T'$+- K%*+,+$-+ ' $0+'0+ '+*+ -'/+

/'0+$%8

1. '*& '0%- '$'0 : -''+- $#&*'$-+-

: -'0 ' /#/# 5<@;

2. $''&+*+$ ' *+ ' '0&-%$ %-%0 $#&+-0+-6+0'$-+ :

/'0'*& '$'0 : -''+- $#&*'$-+- : -'0

' /#/# 4<5;

3. /#/# &-+<&-+ P'0-:0 T'$+- K%*+,+$-+ -'-%+ ' :

+'$ *& LDK.

4. *& * '$'0 $#&*'$- : &'&'0-:0$ -'/+&'0%& *& #$%&' $%*+,+$-+6LDK *& $0+'0+ '+*+ 0%-

+'0+%$ '0-:0 &'&+*+$+ -'0+,+$ &'&' &%% ISO %

'0-:0 *+ -''0+ '0* $%-%- ' *+ -'-+*+- :

+'0*%$ % '*& '0'% %%$ '$'0 $#&*'$- '

/#/# '0'% : /'-0: &'%0+ /#/# '*&

'0%- +'$ *& LDK.

F. P'-'0 : &'&'%+ P'0-:0 T'$+- K%*+,+$-+ +&-%$$ -'/+

"*# D,0 P''$ +*%$ ' P'&/%$+ K%*+,+$-+.

G. A/+* +$ '-'0 % $%0 0+ 5 (*+&) '-'0 : &'&'%+

P'0-:0 T'$+- K%*+,+$-+ &$ -'*'$-+ +:$ *.

>. P++ P' &'&'0+$- &'&/+$ '0-:0

+-+ '-'0 *& D#$%&' K%*+,+$-+ *& *8

1. $'*'$ D#$%&' K%*+,+$-+;

2. '&'% '0-:0 $%*+,+$-+.

I. A/+* +'&%$ *<* 6% : $%0 '*- &$ P++P' &'&+ '-'0 %%$ &':&+$ $*0+,+$-+ -'0

'0%*+- 6% &'*'$+ : $%0 &% +$ /#*' &'%/

-%/--+ D#$%&' K%*+,+$-+.

J. D : $%0 +*'$+ *+ *&/ -'/'*%& /- $+0 

'&-%$ D#$%&' K%*+,+$-+.