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  • 8/16/2019 PQ Perencanaa1n SKPD

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    FORMULIR PENILAIAN KUALIFIKASI PEKERJAAN

     JASA KONSULTANSI

    PENGADAAN JASA KONSULTAN

    PEKERJAAN : JASA KONSULTAN PERENCANAAN GEDUNGPERKANTORAN SKPD (15 UNIT)

    LOKASI : NIAS BARAT

    SUMBER DANA : REVISI DPA – P.APBD DINAS PEKERJAAN UMUMKABUPATEN NIAS BARAT TA. 2012

    TAHUN ANGGARAN : 2012

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    DAFTAR FORMULIR ISIAN PRAKUALIFIKASI

    NO URAIAN

    1. SURAT PENGANTAR DOKUMEN PRAKUALIFIKASI

    2. FAKTA INTEGRITAS

    . FORMULIR ISIAN PENILAIAN KUALIFIKASI

    !. A. DATA ADMINISTRASI

    1. UMUM

    B. IJIN USAHA JASA KONSTRUKSI

    C. LANDASAN HUKUM PENDIRIAN PERUSAHAAN

    D. PENGURUS PERUSAHAAN

    E. DATA KEUANGAN

    1. SUSUNAN KEPEMILIKAN SAHAM

    2. PAJAK  

    F. DATA PESONALIA

    DATA PENGALAMAN PERUSAHAAN

    DATA PEKERJAAN YANG SEDANG DIKERJAKAN

    LAMPIRAN :

    1. AKTE PENDIRIAN PERUSAHAAN

    2. REKAMAN KTP PENGURUS PERUSAHAAN

    3. SERTIFIKAT BADAN USAHA

    4. REKAMAN IJIN USAHA JASA KONSTRUKSI

    5. REKAMAN DATA PERPAJAKAN

    6. DATA PENDUKUNG TENAGA AHLI

    7. REKAMAN BUKTI PENGALAMAN PEKERJAAN

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    SURAT PENGANTAR DOKUMEN PRAKUALIFIKASI

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    PT. SANTO PUTRA ANUGRAH

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    PT. SANTO PUTRA ANUGRAH

     DESIGNER – CONSTRUCTION – ARCITHECT ENGGINERING – SOILINVESTIGATION AND SURVEYING

    Jl. Jangka No. 46 Telp. 6!" 4!#$%6# &a' 6!" 4!#$%6# (e)an %!!*

    NP+P , !. 6$. --*. !" !%4.

    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

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    STRUKTUR ORGANISASIPT. SANTO PUTRA ANUGRAH

    M(+; 6 A$-$ 2'12

    PT. SANTO PUTRA ANUGRAH

    I/. T%"+ P. S&'"$&$," D*!-! U-((

    Ir. TPS.

    R U P S Komisaris

    Direktur Utama

    Direktur I

    Santo DPS

    Divisi Arsitektur

    Ir. Yanuar M, IAI

    Divisi Sipil

    Ir. Togap PS

    Divisi Jasa Survey

    Ir. Morlan T.

    Divisi Jasa

    Management

    Ir. Joan !S,MT

    Divisi Tata

    "ingkungan

    Ir. Tunggul S.

    Kepala Divisi

    Sekretaris

    Asisten Tenaga

    Ali

    Juru #am$ar !%%i&e Manager Pelaksana

    A'ministrasi

    Dan !(

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    F A K T A I N T E G R I T A S

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    NP+P , !. 6$. --*. !" !%4.

    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

    mailto:[email protected]:[email protected]

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    SURAT PERN3ATAAN MINAT

    UNTUK MENGIKUTI PENGADAAN PAKET PEKERJAAN JASA KONSULTANPERENCANAAN GEDUNG PERKANTORAN SKPD (15 UNIT)

    PADA PANITIA PELELANGAN UMUM4 PENUNJUKAN LANGSUNG DANPENGADAAN LANGSUNG JASA KONSULTANSI PERENCANAAN DAN

    PENGAASAN KEGIATAN TAHUN JAMAK TAHUN 2012 – 2015 PADA DINASPEKERJAAN UMUM KABUPATEN NIAS BARAT

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     DESIGNER – CONSTRUCTION – ARCITHECT ENGGINERING – SOILINVESTIGATION AND SURVEYING

    Jl. Jangka No. 46 Telp. 6!" 4!#$%6# &a' 6!" 4!#$%6# (e)an %!!*

    NP+P , !. 6$. --*. !" !%4.

    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

    mailto:[email protected]:[email protected]

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    SURAT PERN3ATAANB(9( B((+ U$(( Y(+ B!$(+-(+ D(+ M(+(++>( T*( D((

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    A((- " J((+ J(+( No. 46 M(+No. T)o+%F(? " ,'61/ 4153265 % ,'61/ 4153265

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    PT. SANTO PUTRA ANUGRAH

     DESIGNER – CONSTRUCTION – ARCITHECT ENGGINERING – SOILINVESTIGATION AND SURVEYING

    Jl. Jangka No. 46 Telp. 6!" 4!#$%6# &a' 6!" 4!#$%6# (e)an %!!*

    NP+P , !. 6$. --*. !" !%4.

    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

    mailto:[email protected]:[email protected]

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    S U R A T P E R N 3 A T A A N

    SALAH SATU DAN%ATAU SEMUA PENGURUS BADAN USAHA TIDAK MASUK DALAMDAFTAR HITAM PERUSAHAAN

     Y(+ 0!-(+(-(+(+ *0(9( *+*"

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    PT. SANTO PUTRA ANUGRAH

     DESIGNER – CONSTRUCTION – ARCITHECT ENGGINERING – SOILINVESTIGATION AND SURVEYING

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    NP+P , !. 6$. --*. !" !%4.

    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

    mailto:[email protected]:[email protected]

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    S U R A T P E R N 3 A T A A N

    MEMPEROLEH PALING SEDIKIT 1 ,SATU/ PEKERJAAN SEBAGAI PENYEDIA JASAKONSULTANSI DALAM KURUN AKTU 4 ,EMPAT/ TAHUN TERAKHIR; BAIK DI

    LINGKUNGAN PEMERINTAH MAUPUN SASTA TERMASUK PENGALAMANSUBKONTRAK

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     DESIGNER – CONSTRUCTION – ARCITHECT ENGGINERING – SOILINVESTIGATION AND SURVEYING

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    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

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    S U R A T P E R N 3 A T A A N

     MEMILIKI KEMAMPUAN PADA SUB BIDANG PEKERJAAN 3ANG SESUAI67

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     DESIGNER – CONSTRUCTION – ARCITHECT ENGGINERING – SOILINVESTIGATION AND SURVEYING

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    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

  • 8/16/2019 PQ Perencanaa1n SKPD

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    S U R A T P E R N 3 A T A A N

    MEMILIKI KEMAMPUAN MENYEDIAKAN FASILITAS DAN PERALATAN SERTAPERSONIL YANG DIPERLUKAN UNTUK PELAKSANAAN PEKERJAAN

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    AN/ , (ANDIRI CA. (EDAN/IRANA

      AN/ SU(UT SYAHRIAH

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    S U R A T P E R N 3 A T A A N

    KEBENARAN DATA

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      AN/ SU(UT SYAHRIAH

  • 8/16/2019 PQ Perencanaa1n SKPD

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    FORMULIR ISIAN PENILAIAN KUALIFIKASI

    PENGADAAN JASA KONSULTANSI JASA KONSULTAN PERENCANAANGEDUNG PERKANTORAN SKPD (15 UNIT)

    PADA PANITIA PELELANGAN UMUM4 PENUNJUKAN LANGSUNG DANPENGADAAN LANGSUNG JASA KONSULTANSI PERENCANAAN DAN

    PENGAASAN KEGIATAN TAHUN JAMAK TAHUN 2012 – 2015 PADA DINASPEKERJAAN UMUM KABUPATEN NIAS BARAT

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      AN/ SU(UT SYAHRIAH

    mailto:[email protected]:[email protected]

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    D(-( A*+*$-!($*

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    A. D"," A;'&$&,/"&

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    F. PENGURUS PERUSAHAAN

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    G.  DATA KEUANGAN

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