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P. JACKSON, MARLBORO MA PLANT MANAGER
W. CARROLL, MERRIMAC MA PLANT MANAGER
D. CLUFF, ROCHESTER / HOOKSETT NH PLANT MANAGER
E. STEVENSON, RE/PCS DIV. SUPERVISOR
S. NEWTON, GRADING SUPERVISOR
L. VALENTE, GRADING FOREMAN
E. WELCH, PAVING SUPT.
F. RAWSON, PAVING SUPT.
R. VILAMARIM, PAVING SUPT.
B. KENNEDY, PAVING FOREMAN
J. SHEA, PAVING FOREMAN
M. BUCUZZO, TRUCKING SUPERVISOR
C. NICKERSON, CONTROLLER
3. LIST THE MEMBERS OF YOUR COMPANY'S JOINT LOSS MANAGEMENT
COMMITTEE BY NAME AND JOB TITLE. PLEASE INDICATE WHICH MEMBERS
REPRESENT THE EMPLOYER AND THOSE WHICH REPRESENT EMPLOYEES, IDENTIFY
CHAIRPERSON.
* MANAGEMENT MEMBERS (SUPERVISORY)
E. STEVENSON (CHAIRMAN), PROJECT MANAGER, RE/PCS DIVISION
D. THOMPSON, PLANT MANAGER, MTLS. DIV.
M. SHEEHAN, SUPERVISOR, CONTRACTING DIV.
* EMPLOYEE MEMBERS (NON-SUPERVISORY)
R. PERETTI, PLANT OPERATOR, MTLS. DIV. (LABOR REP.)
D. ROMA, FOB SALES, SALES/MARKETING DIV.
State of NH
Department of Labor
PO Box 2076
Concord, NH 03302-2076
SAFETY SUMMARY FORM FOR JANUARY 1, 2011
COMPANY NAME: BROX INDUSTRIES, INCORPORATED
COMPANY ADDRESS: 1471 METHUEN ST., DRACUT, MA 01826
N.H. LOCATIONS OF REPORT: HUDSON, HOOKSETT, ROCHESTER, MILFORD
CONTACT PERSON: VICTOR L. GOULET, SAFETY DIRECTOR
PHONE NO: (978) 805-9740 NUMBER OF EMPLOYEES: 180
S.C. CODE: 1611, 1429, 1442, 2951, 7538, 7699 FEDERAL ID. NO.: 04277 2247
6531, 4959 & NAICS 551114
10.
1.
12.
14,
15,
Does your organization now have any legal suits or arbitration claims pending or outstanding
against it or any officers?
[TYes [XJNo
If yes, describe circumstances and provide details on attachment.
Has your organization had a contract partially or completely terminated for default (cause) within
the past five years?
[]Yes [XINo
If yes, describe circumstances and provide details on attachment.
CONSTRUCTION CONTRACTOR’S
QUALIFICATION STATEMENT
On Schedule A, attached, list major engineered construction projects completed by this
organization in the past five (5) years. (If joint venture, list each participant’s projects separately).
ZURICH AMERICAN INSURANCE COMPANY
COLONIAL AMERICAN CASUALTY AND SURETY COMPANY
FIDELITY AND DEPOSIT COMPANY OF MARYLAND
POWER OF ATTORNEY
Ww
Bidder and Surety, jointly and severally, bind
themselves, their heirs, executors, administrators, 7.
successors, and assigns to pay to OWNER upon
default of Bidder the penal sum set forth on the face
of this Bond.
Bm BOND
PENAL SUM FORM
BIDDER (Name and Address):
Brox Industries, Inc.
1471 Methuen Street
Dracut MA 01826-5439
SURETY (Name and Address of Principal Place of Business):
Fidelity and Deposit Company of Maryland
1299 Zurich Way, 5th Floor
Schaumburg, IL 60196-1056
OWNER (Name and Address):
City of Nashua, NH
Central Purchasing 229 Main Street City Hall Room 128
Nashua, NH 03061-2019
LIST OF SUBCONTRACTORS
(to be submitted after bid opening)
LIST OF SUBCONTRACTORS
(to be submitted with bid)
The name and address of each subcontractor who will be paid at least five percent (5%) of the prime
contractor's total bid shall be listed below. To be deemed a responsive bid, this form must be submitted
even if no subcontractors are required to be listed. In that case, the bidder should state “None” (or similar
language stating that no subcontractors need to be listed) in the space below. (Refer to General Condition
6.09.H)
