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8/16/2019 PQ Perencanaa1n SKPD

1/37

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


2/37

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


3/37

SURAT PENGANTAR DOKUMEN PRAKUALIFIKASI

Noo! " 11 # A!$ %PT.SPA%&III%2'12

L()*!(+ " 1 ,$(-/ 0!($

K)(( Y- "

P(+*-*( P(+(+ U% P++(+ L(+$+(+ P+(((+ L(+$+ J($( Ko+$-(+$* P!+8(+((+(+ P+(9($(+ *(-(+ T(+ J(( T(+ 2'12 # 2'15)(( D*+($ P!((+ U K(0)(-+ N*($ B(!(-

T(+ A+(!(+ 2'12* # J"#"$ O$%#&' – L"*%'& K"+",-$ N&" B"/", P!*( " Do+ P!((*:($*

D+(+ Ho!(-;

S0+(+ +(+ P+(+ P!((*:($* P!((+ J($( Ko+$-(+$*Noo! '7%P(+.PU$+ o+ )!((*:($* -!$0- $-( +*-* (+ ((* *$*o+ )!((*:($* (+ ()*!(++>(.

2. K(* ((* 0(9( "3. K0+(!(+ (+ -)(-(+ )!+>(-((+; (9(0(+ (+ (-( >(+ *()*!(+ )((

o+ )!((*:($*. K(* $- 0(9( "(. S(( 0*(>( >(+ -( (* (!(+ +- )+>$+(+ o+ )!((*:($*

(+ ()(0*( *+(+ +- (!*:($* (( 0*(>( -!$0- -*( (* *+-((+)+(+-*(+ (!* P!o> (+ P(+*-*(

0. P++( ($( %P(+*-*( -*( -!*(- +- +>-* $(+ (* (+ -*(-!*(- +- 0!* (($(+ )+o((+

4. S!(- +>!(- ++(* ( *+* oo+ *-(+ (((- (* $0((* 0!*- " J. J(+( No. 46 M(+

D**(+( S!(- P+(+-(! Do+ P!((*:($* *+* (* $()(*(+ +- 0((+$$* (+ -!*( ($*.

M(+; 6 A$-$ 2'12Ho!(- (*;

PT. SANTO PUTRA ANUGRAH

I/. T%"+ P. S&'"$$," D*!-! U-((


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


4/37

STRUKTUR ORGANISASIPT. SANTO PUTRA ANUGRAH

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


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 !(


5/37

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

S(>( >(+ 0!-(+( -(+(+ *0(9( *+*"N(( " I!. To() P. S*(++-(No. I+-*-($ " 1271'1'6'5=''''7

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T)o+%F(? " ,'61/ 4153265

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4. A)(0*( $(>( (+(! ((+ -( $(>( +>(-((+ (( FAKTA INTEGRITAS*+*; $(>( 0!$*( *+((+ $(+$* o!(; $(+$* (*+*$-!($* $!-( *-+-- (+-*!* (+ )*(+( $$(* +(+ -+-(+ )!(-!(+ )!+(+ +(+(+ >(+0!(.

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


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


AN/ SU(UT SYAHRIAH

mailto:[email protected]:[email protected]


6/37

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

Y(+ 0!-(+( -(+(+ * 0(9( *+* "

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No. T)o+%F(? " '61 # 4153265% '61 # 4153265% '=126'53=

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M+>(-((+ +(+ $0+(!+>( 0(9( $-( +-(* )+(((+ >(+((+ *($(+((+ o P(+*-*( P(+(+ U% P++(+ L(+$+ (+P+(((+ L(+$+ J($( Ko+$-(+$* P!+8(+((+ (+ P+(9($(+ *(-(+

T(+ J(( T(+ 2'12 # 2'15 )(( D*+($ P!((+ U K(0)(-+ N*($B(!(-; T(+ A+(!(+ 2'12; (( +(+ *+* $(>( +>(-((+ 0!*+(- +-+*-* )!o$$ )+(((+ )(- )!((+ " JASA KONSULTANPERENCANAAN GEDUNG PERKANTORAN SKPD (15 UNIT) $()(* $$(*

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


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


AN/ SU(UT SYAHRIAH



7/37

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

P+(9($(+ P+(*(+; T*( B(+!-; D(+ T*( S(+ D*+-*(+ K*(-(+U$((+>(

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N(( " I/. T%"+ P. S&'"$$,"

J(0(-(+ " D*!-! U-((

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(+ (-($ +(( " PT. SANTO PUTRA ANUGRAH

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

E(* " $(+-o8@'7>(oo.8o

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


AN/ SU(UT SYAHRIAH



8/37

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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No. T)o+%F(? " ,'61/ 4153265 % ,'61/ 4153265

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2. D**(+ )!+>(-((+ (* 0(- (+ )+* +(+ )+ $((!(+ -(+)((( )($((+ (!* )*( (+()+ (+ )+ !($( -(++(9(0.

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


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AN/ SU(UT SYAHRIAH



9/37


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

LINGKUNGAN PEMERINTAH MAUPUN SASTA TERMASUK PENGALAMANSUBKONTRAK

Y(+ 0!-(+(-(+(+ *0(9( *+*"

N(( " I!. To() P. S*(++-(

T)(- (+ T(+( L(*! " B(*% '6 A)!* 156A((- " J. P(!9*-(>($( II L. & No. 16 G()!-( U+

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


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AN/ SU(UT SYAHRIAH


10/37


MEMILIKI KEMAMPUAN PADA SUB BIDANG PEKERJAAN 3ANG SESUAI67

Y(+ 0!-(+(-(+(+ *0(9( *+*"

N(( " I!. To() P. S*(++-(


M(+

T)o+ " '61(+ $(>( )*)*+ 0+(! M*** K()(+ P(( S0B*(+ P!((+ Y(+ S$(* >(*- P!+8(+((+ P0(++(+ S(!(+( (+P!($(!(+( G+ (+ L*++(+ POLTEKKES DEPKES M(+ ,KSO PT. YODYAKARYA # PERSERO/ $0$(! R). 1.85.925.000.00 (", '&"/ ;-#"+"$ /",,&" +#* #&'" ," ,* /", ;" +#* #&'" /& /+&"*)

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


AN/ SU(UT SYAHRIAH


11/37


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

Y(+ 0!-(+(-(+(+ *0(9( *+*"

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


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AN/ SU(UT SYAHRIAH


12/37


KEBENARAN DATA

Y(+ 0!-(+(-(+(+ *0(9( *+*"

N(( " I!. To() P. S*(++-(

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


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


AN/ SU(UT SYAHRIAH


13/37

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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No. T)o+%F(? " '61 < 4153265 % '61 < 4153265

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14/37

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


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F. PENGURUS PERUSAHAAN

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33/37

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34/37

NERACA PERUSAHAAN PT. SANTO PUTRA ANUGRAH

PERIODE 31 D$0! 2'11

A K T I V A P A S S I V A

I. A,&" L"$?"/ IV. K-="&"$ L"$?"/

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35/37

PERHITUNGAN RUGI LABA

PERIODE 1 JANUARI 2011 S4D DESEMBER 2011

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36/37

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PT. SANTO PUTRAANUGRAH

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