PT.

PAM LYONNAISE JAYA

PRE-QUALIFICATION DOCUMENT
DOKUMEN PRAKUALIFIKASI
No. : PROC-001/PESANGGRAHAN/PRE-QUAL/I/2014
FOR
UNTUK
PESANGGRAHAN WATER TREATMENT PLANT PROJECT
INSTALASI PENGOLAHAN AIR PESANGGRAHAN
PT PAM Lyonnaise Jaya, Sentral Senayan I Offie To!er, "
t#
Floor Jl$ Asia Afri%a No &, Senayan ' Ja%arta ()*") '
INDONESIA Tel+ )*(',"*--().H/ntin01, Fa2+ )*(',"*--(&,*3
JANUARY 2014
PRE-QUALIFICATION DOCUMENT LOCAL
COMPETITIE !IDDING "o# PESANGGRAHAN
WATER TREATMENT PLANT PROJECT
I. NOTICE OF PRE-QUALIFICATION
($($ 4it#in t#e fra5e!or% of PT PAM Lyonaisse Jaya
.6PALYJA71 8 Per/sa#aan Air Min/5 Daera#
K#/s/s I9/ Kota Ja%arta .6PAM JAYA71 as
o:erator in t#e fiel; of :ro<ision an; i5:ro<e5ent
of !ater ser<ies in t#e 4estern re0ion of Ja%arta,
inten;s to :re'=/alifiation :roess for t#e
Pesan00ra#an 4ater Treat5ent Plant Pro>et$
inl/;es t#e s/::ly of e=/i:5ent an; relate;
ser<ies .installation, testin0 o55issionin0 an;
relate; staff trainin0, !#ere a::lia9le1$ T#e
:ro/re5ent :roe;/re !ill follo! ter5 an;
on;ition in PAL?JA re0/lation$ Pre'@/alifiation
for Ai;;in0 Tea5 is o:en to all national ontrators
as !ell as #a<in0 e2:eriene in ;esi0n an; 9/il; of
!ater treat5ent :lant !it# a:aity 5ini5/5 (*))
l:s, a9le to treat !ater !it# a55oni/5, iron,
5an0anese an; ;eter0ent ontent$
($*$ T#e E2e/tin0 A0eny, PAL?JA #as a::ointe; t#e
Ai;;in0 Tea5 to at on its 9e#alf, to /n;erta%e :re'
=/alifiation .#ereinafter alle; 6PB@71 :roe;/re
an; selet =/alifie; fir5s for 9i;;in0$ T#e ;eision
of :artii:ants !#o :asse; t#e :re=/alifiation
9ase; on Ai;;in0 Co55ittee e<al/ation is
a9sol/te an; in<iola9le$
Fir5s or Consortia .#ereinafter alle;
DA$$%&'()*D1 !#o are intereste; in PB@ are in<ite;
to s/95it PB@ ;o/5ent as re=/este; an; ;esri9e;
#ereinafter$
DO+UMEN PRA+UALIFI+ASI LOCAL
COMPETITIVE BIDDING ,)*,- PROYE+
INSTALASI PENGOLAHAN AIR
PESANGGRAHAN
II. PENGUMUMAN PRA-+UALIFI+ASI
($($ PT PAM Lyonaisse Jaya .6PALYJA71 se9a0ai
o:erator Per/sa#aan Daera# Air Min/5
Pe5erinta# Pro<insi Deara# K#/s/s I9/%ota
Ja%arta .6PAM JAYA71 ;ala5 :enye;iaan ;an
:enin0%atan :elayanan air 9ersi# ;i !ilaya# Aarat
DKI Ja%arta, 9er5a%s/; /nt/% 5en0a;a%an :roses
Pra%/alifi%asi /nt/% Proye% Instalasi Pen0ola#an
Air Pesan00ra#an ter5as/% ;i ;ala5nya
:en0a;aan :eralatan ;an >asa'>asa yan0
9er#/9/n0an .instalasi, testin0'o55isionin0, ;an
staff trainin0 .>i%a ;i:erl/%an1$ Prose;/r :elelan0an
a%an 5en0i%/ti %etent/an ;an :ersyaratan yan0
9erla%/ ;i PAL?JA$ Pra%/alifi%asi /nt/% Ti5
Lelan0 ter9/%a /nt/% %ontra%tor nasional .5ini5al
Gra;e E1 serta 5e5ili%i :en0ala5an ;ala5 ;esain
;an :e59an0/nan instalasi :en0ola#an air ;en0an
%a:asitas 5ini5al (*)) literB;eti% ;an 5a5:/
5en0ola# air 9a%/ ;en0an %an;/n0an a55oni/5,
9esi, 5an0an ;an ;eter>en$
($*$ Le59a0a Pela%sana, PAL?JA tela# 5en0an0%at
Ti5 Lelan0 /nt/% 5ela%/%an :rose;/r :ra'
%/alifi%asi ./nt/% selan>/tnya ;ise9/t 6PB@71 ;an
5ela%/%an sele%si :e5ili#an :er/sa#aan yan0
5e5en/#i syarat /nt/% :elelan0an$ Ke:/t/san
:eserta :elelan0an yan0 l/l/s :ra %/alifi%asi
9er;asar%an e<al/asi Ti5 Lelan0 a;ala# 5/tla%
;an ti;a% ;a:at ;i0an00/ 0/0at$
Per/sa#aan ' :er/sa#aan ata/ Konsorsi/5 ./nt/%
selan>/tnya ;ise9/t 6P./.#*(71 yan0 9er5inat
;ala5 PB@ ;i/n;an0 /nt/% 5e5as/%an ;o%/5en
PB@ se:erti yan0 ;i:ersyarat%an ;an ;i>elas%an
;ala5 9a0ian selan>/tnya$
($3$ T#e A::liant 5ay re0ister an; o9tain PB@s ;o/5ent 9e0innin0 *&
t#
of Jan/ary *)(- /ntil E
t#
of Fe9r/ary *)(-, )&$3) to (E$)) 4IA #o/rs, at +
D.$(#*0.)* P#o',#.0.)*:
G.1,)2 P,/(* Lo2&/*&- L* 1 J% P.)3.#)&4() I5
+.% +(#.* T.)2/&) J(-(#*( P,/(* 10220
($-$ T#e o5:lete; PB@ ;o/5ent s#all 9e s/95itte; at
t#e follo!in0 a;;ress not later t#an 10
*4
o"
F.6#,(#7 20145 18:00 WI! 4o,#/$
!&11&)2 Co00&**..
PT PAM L7o))(&//. J(7(
+()*o# P,/(*5 G.1,)2 S.)*#(% S.)(7() I5
L()*(& 95 J%. A/&( A"#&-( No : S.)(7()
J(-(#*( 10290 ; INDONESIA5
T.%$: 021-8924410<4,)*&)2=5 "(>: 021-89244?2
($,$ Pesan00ra#an 4ater Treat5ent Plan Pro>et to 9e
:ro/re; !ill 9e ten;ere; t#ro/0# PAL?JA
:roe;/re$ PAL?JA #as f/ll le0al :o!er F
a/t#ority to anelB:ost:one t#e ten;er :roess at
any ti5e 9y notie in !ritin0 to all A::liants$
($E$ T#e Ten;er Co55ittee !ill e<al/ate t#e A::liants
PB@ ;o/5ent an; only =/alifie; A::liant !ill 9e
notifie; to :artii:ate in t#e 9i;;in0 for !#i# lot
t#ey are :re=/alifie; or for t#e ne2t :roess$ T#e
Ten;er Co55ittee !ill <isit 5an/fat/re :lantG to
0ain infor5ation nee;e; o5:letin0 A::liant
e<al/ation :roess$
($" T#e Ten;er Co55ittee reser<es t#e ri0#t to <erify,
in<esti0ate an; to <al/e any state5ents or lai5s
5a;e an; f/rnis#e; 9y t#e A::liants, inl/;in0
s/::ortin0 e<i;ene an; its le<el of onfi;ene,
an; to on;/t any a::ro:riate ation, le0ally or
a;5inistrati<ely$
($3$ Peserta 9isa 5en;aftar%an ;an 5en0a59il 9er%as
;o%/5en PB@ se>a% tan00al *& Jan/ary *)(-
sa5:ai ;en0an tan00al E Fe9r/ary *)(- P/%/l
)&$3) sB; (E$)) 4IA, ;i+

D.$(#*.0.) P#o',#.0.)*:
G.1,)2 P,/(* Lo2&/*&- L* 1 J% P.)3.#)&4() I5
+.% +(#.* T.)2/&) J(-(#*( P,/(* 10220
($-$ Do%/5en PB@ yan0 lela# ;ilen0%a:i #ar/s
;i%e59ali%an ;an ;i%iri5%an :a;a ala5at terse9/t
;i 9a!a# ini :alin0 la59at 10
*4
F.6#,(#7 20145
3(0 18:00 WI!$
!&11&)2 Co00&**..
PT PAM L7o))(&//. J(7(
+()*o# P,/(*5 G.1,)2 S.)*#(% S.)(7() I5
L()*(& 95 J%. A/&( A"#&-( No : S.)(7()
J(-(#*( 10290 ; INDONESIA5
T.%$: 021-8924410<4,)*&)2=5 "(>: 021-89244?2

($,$ Proye% Instalasi Pen0ola#an Air Pesan00ra#an
a%an ;ilelan0%an 5en0i%/ti :rose;/r PAL?JA$
PAL?JA 5e5:/nyai %e%/asaan ;an %e%/atan
#/%/5 seara :en/# /nt/% 5e59atal%an
B5en/n;a :roses ten;er %a:an sa>a ;en0an
5e59erita#/%an seara tert/lis %e:a;a Peserta
ten;er$
($E$ Ti5 Lelan0 a%an 5en0e<al/asi ;o%/5en PB@
Peserta ;an #anya Peserta yan0 5e5en/#i
:ersyaratan yan0 a%an ;i/n;an0 /nt/% i%/t serta
;ala5 :elelan0an ata/ ;ala5 :roses selan>/tnya $
Ji%a ;i:erl/%an Ti5 Lelan0 a%an 9er%/n>/n0 %e
:lan 5an/fa%t/r /nt/% 5en;a:at%an infor5asi
yan0 ;i:erl/%an 0/na 5elen0%a:i :roses e<al/asi
Peserta $
($" Ti5 Lelan0 5e5:/nyai #a% /nt/% 5eneliti,
5enyeli;i%i ;an 5enilai se5/a :ernyataan yan0
;i9/at ole# Peserta, ter5as/% ;o%/5en 9/%ti
:en;/%/n0 ;an tin0%at %e:erayaannya, ;an /nt/%
5en0a;a%an tin;a%an yan0 ses/ai, seara le0al
ata/ a;5inistratif$
In ase ;/rin0 t#e e<al/ation of PB@, A::liantHs intentionally 5islea;in0 an; false state5ent are
;etete; in t#e infor5ation s/95itte;, t#e
A::liant s#all 9e onsi;ere; ;is=/alifie;$
S#o/l; it 9e later ;iso<ere; t#at =/alifiation of
A::liant !as o9taine; t#ro/0# 5islea;in0,
a59i0/o/s or false state5ents or erroneo/s
infor5ationG t#e =/alifie; A::liant s#all 9e
;is=/alifie; 9efore, ;/rin0 or after t#e 9i;;in0
II. INSTRUCTION TO APPLICANTS FOR
PRE-QUALIFICATION
GENERAL PROISION
*$($ PB@ ;o/5ents s#all 9e s/95itte; only in an; on
t#e *$($ for5s of 6Pre'=/alifiation Do/5ent F
For5s7 as :er Atta#5ent ($ A;;itional s#eets, if
neessary, s#all 9e :re:are; in t#e sa5e for5at
/nless ot#er!ise s:eifially note;$
*$*$ If t#e A::liants #a<e any =/eries re0ar;in0 t#e
PB@, *$*$ re=/ests for larifiation s#o/l; 9e
s/95itte; in !ritin0 9y fa2 or e5ail to t#e
follo!in0 a;;ress+
I( 9y Fa2 to Pro/re5ent De:t, Fa2 No+ )*('
,"-E)(( or
I* 9y E'5ail to ari$!i9o!oJ:aly>a$o$i;
not later t#an E
t#
of Fe9r/ary *)(-$ Ten;er
Co55ittee is not res:onsi9le for any late ;eli<ery$
Offiial ans!ers to all =/eries an; any a;;itional
infor5ation as re=/ire; !ill 9e ans!er to all
a::liants on "
t#
Fe9r/ary *)(-$ T#e a;;itional
infor5ation or 5inor #an0es to larify t#e ontent
of t#is ;o/5ent !ill 9e re0ar;e; as an inte0ral
:art of t#is PB@ ;o/5ent$
Dala5 #al sela5a e<al/asi PB@, Peserta sen0a>a
5e59eri%an :ernyataan yan0 5enyesat%an ;an
ti;a% 9enar ;ala5 infor5asi yan0 ;i9eri%an,
Peserta ;inyata%an 0/0/r
A:a9ila %e5/;ian ;ite5/%an 9a#!a %/alifi%asi
Peserta ;i;a:at%an 5elal/i :enyala#'0/naan yan0
5enyesat%an, :ernyataan yan0 sala# ata/
5era0/%an ata/:/n infor5asi yan0 ti;a% 9enar,
%/alifi%asi Peserta a%an ;i0/0/r%an 9ai% se9el/5,
;ala5 :roses ata/ setela# lelan0$
II. PETUNJU+ UNTU+ PESERTA
PRA+UALIFI+ASI
PETUNJU+ UMUM
*$($ Do%/5en';/%/5en PB@ #ar/s ;is/s/n ;ala5
for5at'for5at 6Do%/5en'Do%/5en Pra'
%/alifi%asi7 se9a0ai5ana terant/5 ;ala5
La5:iran ($ Le59aran ta59a#an, 9ila ;i:erl/%an,
;a:at ;i:ersia:%an ;ala5 for5at yan0 sa5a
%e/ali ;itent/%an lain$

*$*$ Aila Peserta 5e5erl/%an :en>elasan 5en0enai PB@,
:ertanyaan':ertanyaan terse9/t #ar/s ;isa5:ai%an
seara tert/lis 5elal/i fa2 ata/ e5ail %e ala5at
9eri%/t+
;en0an Fa2 %e Pro/re5ent De:t %e No$ Fa2
No+)*(',"-E)((
;en0an E'5ail %e ari$!i9o!oJ:aly>a$o$i;
sa5:ai ;en0an tan00al E
t#
Fe9r/ary *)(-$ Ti5
Pelelan0an ti;a% 9ertan00/n0 >a!a9 ter#a;a:
%eterla59atan ;ala5 :enya5:aian ;o%/5en$
Ja!a9an res5i ter#a;a: se5/a :ertanyaan ;an
setia: ta59a#an infor5asi yan0 ;i:erl/%an a%an
;i>a!a9 :alin0 la59at tan00al "
t#
Fe9r/ary *)(- %e
se5/a :eserta$ Ta59a#an infor5asi ata/
:er/9a#an':er/9a#an %eil /nt/% 5en0%larifi%asi
isi ;o%/5en ini ;ian00a: se9a0ai 9a0ian yan0 ta%
ter:isa#%an ;ari ;o%/5en PB@$
*$-$ All A::liants 5/st #a<e an :er5anent offie,
!or%s s#o: an; e=/i:5ent stora0e , 9e a9le to
:ro<i;e after'sale ser<ies an; #a<e s:are :arts
a<aila9le in In;onesia$
*$,$ All PB@ ;o/5ents an; ot#er relate; infor5ation
s/95itte; 9y t#e A::liants !ill 9e onsi;ere;
stritly onfi;ential an; are not ret/rna9le$ All
e2:enses of A::liants relatin0 to PB@ :roe;/res
s#all 9e 9orne 9y t#e A::liants an; any ost
in<ol<e; s#all not 9e rei59/rse;$
*$E$ T#e Ten;er Co55ittee !ill infor5 all A::liants
t#e res/lt of t#eir a::liation$ Ten;er Co55ittee
reser<es t#e ri0#t to re>et or ae:t any a::liation
an; to ann/l t#e PB@ :roess an; re>et all
A::liation, !it#o/t t#ere9y in/rrin0 any lia9ility
to t#e effete; A::liants or any o9li0ation to
infor5 t#e A::liants t#e 0ro/n; for t#e ation
ta%en 9y Ten;er Co55ittee
PRE QUALIFICATION FORMS
*$"$ T#e PB@ ;o/5ent ontains t#e follo!in0 for5s+
For5 ($( State5ent Letter
For5 ($* Delaration of Un;erta%in0
Le0al A;5inistrati<e Do/5ent
For5 *$( General Infor5ation
Co5:any Profile
For5 *$* Co5:any E2:eriene
Finanial Re:ort a/;itte;
Ot#er s/::ortin0 ;o/5ents
*$-$ Se5/a Peserta ;i!a>i9%an /nt/% 5e5:/nyai
%antor res5i, area :a9ri%asi ;an 0/;an0 :eralatan,
yan0 ;a:at 5enye;ia%an layanan :/rna >/al
*$,$ Sern/a ;o%/5en PB@ ;an %eteran0an lain yan0
ter%ait yan0 ;isera#%an Peserta a%an ;ian00a:
ra#asia ;an ti;a% ;a:at ;i%e59ali%an$ Se5/a
:en0el/aran Peserta yan0 ter%ait :rose;/r PB@
;itan00/n0 ole# Peserta ;an 9iaya a:a:/n yan0
ter%ait ti;a% a%an ;i0anti$
*$E$ Ti5 Lelan0 a%an 5e59erita#/%an %e:a;a se5/a
Peserta tentan0 #asil PB@ 5asin0'5asin0 Peserta$
Ti5 Lelan0 9er#a% 5enola% ata/ 5eneri5a setia:
:er5o#onan ;an 5e59atal%an :roses PB@ ;an
5enola% se5/a :er5o#onan tan:a %e!a>i9an
/nt/% 5en>elas%an %e:a;a Peserta alasan'alasan
;ari tin;a%an yan0 ;ia59il ole# Ti5 Lelan0$
FORMAT PRA+UALIFI+ASI
*$"$ Do%/5en PB@ 9erisi for5at'for5at ;i 9a!a# ini+
For5 ($( S/rat Pernyataan
For5 ($* Pa%ta Inte0ritas
Do%/5en A;5inistratif %ea9sa#an Per/sa#aan
For5 *$( Infor5asi U5/5
Profil Per/sa#aan
For5 *$* Pen0ala5an Per/sa#aan
La:oran Ke/an0an tera/;it
Do%/5en Pen;/%/n0 BTa59a#an
*$&$ If neessary, a;;itional s#eets 5ay 9e a;;e; to
t#ose for5s$ Ea# :a0e of ea# for5 s#o/l; 9e
learly 5ar%e; on t#e ri0#t orner as follo!s For5
(, :a0e (G For5 (, :a0e *G For5 (, :a0e 3G et$
*$K$ Ea# PB@ !ill re=/ire atta#5ent inl/;in0
s/::ortin0 ;o/5ents e<i;enin0 t#e <ali;ity of
;ata F infor5ation s/::lie;$ S/# atta#5ent
s#o/l; 9e learly 5ar%e; as follo!s$ Atta#5ent (
to For5 I, Atta#5ent * to For5 ( et$
SU!MISSION OF APPLICATION
*$()$ A::liation s#all 9e s/95itte; in 1 <o).= o#&2&)(%
an; 2 <*@o= 'o$&./ in 1 <o).= seale; .)A.%o$.$
T#e en<elo:e onsistin0 of+
A10&)&/*#(*&A. R.B,&#.0.)*/ s#all inl/;e t#e
follo!in0 ;o/5ents an;Bor for5s ;/ly fille; in+
I( For5 ($( Letter of A::liation
I* For5 ($* Delaration of Un;erta%in0
I3 Le0al A;5inistrati<e Data
Co0$()7 C($(6&%&*&./ s#all inl/;e t#e follo!in0
;o/5ents an;Bor For5s ;/ly fille; in+
I- For5 *$( General Infor5ation
I, Co5:any Profile
IE For5 *$* Co5:any E2:eriene
I" Finanial Re:ort
I& Ot#er S/::ortin0 Do/5ent
T#e en<elo:e s#all 9e 5ar%e; in t#e /::er left
#an; orner !it# t#e !or;s 6APPLICATION FOR
PRE@UALIFICATION FOR PESANGGRAHAN
4ATER TREATMENT PLANT PROJECT7 an;
9e a;;resse; :/rs/ant to Cla/se ($- a;;resses$ T#e
na5e an; 5ailin0 a;;ress of t#e A::liants s#all
also 9e in;iate; on t#e o/ter en<elo:e so t#at t#e
late s/95issions an 9e ret/rne; /no:ene;$
*$& Ji%a ;i:erl/%an le59ar'le59ar ta59a#an ;a:at
;iserta%an :a;a for5at'for5at terse9/t$ Tia:'tia:
le59ar ;ari for5at'for5at terse9/t #en;a%nya
;i9eri tan;a ;en0an >elas ;i s/;/t ;i se9ela# %anan
atas se9a0ai 9eri%/t+ For5at (, #ala5an (, For5at
( #ala5an *, For5at ( #ala5an 3 ;an seter/snya$
*$K$ Setia: PB@ a%an 5e5erl/%an la5:iran ter5as/%
;o%/5en';o%/5en :en;/%/n0 yan0 5e59/%ti%an
%ea9sa#an ;ari ;ata F infor5asi yan0
;isa5:ai%an$ La5:iran'la5:iran terse9/t
#en;a%nya ;i9eri tan;a ;en0an >elas se9a0ai
9eri%/t+ La5:iran ( /nt/% For5at I, La5:iran *
/nt/% For5at I ;an seter/snya$
PENYAMPAIAN APPLI+ASI
*$()$ A:li%asiBPer5o#onan :ra'%/alifi%asi #en;a%nya
;ia>/%an ;ala5 9ent/% 1 </(*,= 1o-,0.) (/%& ;an
2 <1,(= 'o$7 ;ala5 1 </(*,= /(0$,% tert/t/:$
Sa5:/l 9erisi%an+
P.#/7(#(*() A10&)&/*#(/& 9erisi%an ;o%/5en ;an
for5at yan0 s/;a# ;i'isi+
IK For5at ($( S/rat Pernyataan
I() For5at ($* Pa%ta Inte0ritas
I(( Do%/5en A;5istratif Kea9sa#an Per/sa#aan
+.0(0$,() P.#,/(4(() 6.#&/&-() ;o%/5en
Bforrnat yan0 s/;a# ;iisi+
I(* For5 *$( Infor5asi Urn/5
I(3 Profil Per/sa#aan
I(- For5 *$* Pen0ala5an Per/sa#aan
I(, La:oran Ke/an0an
I(E Do%/5en Pen;/%/n0 B Ta59a#an
Sa5:/l ini #en;a%nya ;i9eri tan;a :a;a s/;/t %iri
atas, 7APPLIKASI B PERMOHONAN PRA'
KUALIFIKASI UNTUK PRO?EK INSTALASI
PENGOLAHAN AIR PESANGGRAHAN7 ;an
;i%iri5%an ses/ai ;en0an ala5at ;i Pasal ($-$
Na5a ;an ala5at Peserta #en;a%nya >/0a
;iant/5%an ;i Sa5:/l terse9/t, se#in00a .s/rat1
:en0a>/an yan0 terla59at .;atan01 ;a:at
;i%iri5%an %e59ali ;ala5 %ea;aan ti;a% ;i9/%a$
EALUATION OF APPLICATION FOR PRE-
QUALIFICATION
*$(( Ten;er Co55ittee !ill ;eter5ine le<el of
o5:liane of ea# A::liant to t#e PB@ riteria$
A::liations s/9stantially not res:onsi<e to t#e
PB@ re=/ire5ents s#all 9e ;is=/alifie;, an; s#all
not 9e in<ite; for 9i;;in0
*$(* E2:eriene, finanial an; te#nial a:a9ility !ill
9e o5:are; !it# a :re;eter5ine; set of
5ini5/5 <al/es$ In or;er to 9e :re'=/alifie;, t#e
A::liant 5/st attain at least t#e 5ini5/5 <al/e
for ea# e<al/ation o5:onent$
*$(3 E<al/ation Criteria +
($ A;5inistrati<e Re=/ire5ent A::liant s#all 9e
in :ossession of an; s/95it a le0aliLe; o:y of
;o/5ent re0ar;in0 le0al stat/s of A::liant$
All ;o/5ent re=/este; /n;er t#is ate0ory
s#all 9e onsi;ere; 5an;atory an; fail/re to
f/rnis# any one or 5ore of t#e sai; ;o/5ents
in ter5s of infor5ation an; <ali;ity onstit/tes
s/ffiient 0ro/n; to ;is=/alify t#e
orres:on;in0 a::liation$
*$ Co5:any Ca:a9ilities of ea# A::liant !ill 9e
>/;0e; on t#e 9asis of Te#nial F Finanial
Do/5ent s/95itte; 9y A::liant in ter5s of
infor5ation :ro<i;e; an; <ali;ity of
infor5ation$
Sorin0 syste5 .sorin0 F !ei0#tin01 !ill 9e
a::lie; to e<al/ate+
' A9sene of reasons for e2l/sion :/rs/ant
to la/se *$(* For5 ($*G
' E2:eriene in t#e e2e/tion of
o5:ara9le :ro>etsG
' A;e=/ate finanial a:aity
S/::ortin0 ;o/5ent >/stifyin0 <ali;ity of
infor5ation !ill 9e also <al/e; in ter5 of its
orres:on;in0 le<el of onfi;ene
EALUASI TERHADAP APLI+ASI PRA-
+UALIFI+ASI
*$(( Ti5 Lelan0 a%an 5enent/%an tin0%at :e5en/#an
:enilaian ;ari 5asin0'5asin0 Peserta :a;a %riteria
PB@$ Peserta yan0 ti;a% ;a:at 5e5en/#i
:ersyaratan inti yan0 tela# ;itent/%an ;inyata%an
0/0/r, ;an ti;a% a%an ;ii%/tserta%an ;ala5
:elelan0an$
*$(* Pen0ala5an, %e5a5:/an finansial ;an te%nis a%an
;i9an;in0%an ;en0an ;aftar nilai 5ini5/5 yan0
s/;a# le9i# ;a#/l/ ;iteta:%an$ Unt/% ;a:at
;i:an;an0 5e5en/#i :ersyaratan, Peserta #ar/s
;a:at 5e5en/#i syarat 5ini5/5 ;ala5 setia:
%o5:onen e<al/asi$
*$(3 Kriteria E<al/asi+
($ Persyaratan A;rninistrasi Peserta #ar/s
5e5ili%i ;an 5enyera#%an salinan o:y yan0
sa# ;ari ;o%/5en tentan0 le0alitas stat/s ;ari
Peserta$ Sel/r/# ;o%/5en yan0 ;i:ersyarat%an
;ala5 %ate0ori ini 9ersifat !a>i9 ;an %eti;a%'
5a5:/an /nt/% 5enyera#%an sala# sat/ ata/
le9i# ;o%/5en yan0 ;i5a%s/; 9ai% ;ari se0i
infor5asi 5a/:/n %ea9sa#an, 5e59eri%an
;asar yan0 /%/: /nt/% 5en00/0/r%an
:er5o#onan yan0 9ersan0%/tan$
*$ Ke5a5:/an Per/sa#aan ;ari setia: Peserta
a%an ;iteta:%an 9er;asar%an Do%/5en Te%nis
;an Finansial yan0 ;isera#%an ole# Peserta
;inilai 9ai% ;ari s/9stansi infor5asi 5a/:/n
%ea9sa#an infor5asi$
Siste5 Sorin0 .siste5 s%or ;an 9o9ot1 a%an
;itera:%an /nt/% 5ela%/%an e<al/asi+
' Ke9era;aan alasan :en0e/alian ses/ai
;en0an :asal *$(* For5at ($*G
' Pen0ala5an 5ela%sana%an :roye%
ser/:aG
' Ke5a5:/an %e/an0an
Do%/5en :en;/%/n0 %ea9sa#an infor5asi
>/0a a%an ;inilai 9er;asar%an tin0%at
%e:erayaan ;ari ;o%/5en terse9/t$
$
*$(- In ase ;isre:anies are fo/n; in t#e
infor5ation s/95itte;, t#e ;o/5ent s#all 9e
onsi;ere;, /nsatisfatory, an; t#e A::liant
s#all 9e ;is=/alifie;$ T#e Ten;er Co55ittee
!ill not on;/t !ritten o55/niation !it#
a::liant for PB@, /nless a;;itional larifiation
is onsi;ere; neessary
*$(, T#e ;eision of Ten;er Co55ittee to ae:t or
re>et any a::liation for PB@ !ill 9e final an;
in<iola9le
*$(- A:a9ila ;ite5/%an :enyi5:an0an ;ala5
infor5asi yan0 ;i9eri%an, 5a%a ;o%/5en a%an
;ian00a: ti;a% 5e5en/#i syarat, ;an Peserta
;ian00a: ti;a% laya% /nt/% i%/t :ena!aran$
Ti5 Lelan0 ti;a% 5en0a;a%an s/rat 5eny/rat
;en0an :eserta PB@, %e/ali /nt/% 5en;a:at
:en>elasan a:a9ila ;ian00a: :erl/
*$(, Ke:/t/san Ti5 Lelan0 /nt/% 5eneri5a ata/
5enola% setia: :er5o#onan PB@ a;ala#
%e:/t/san yan0 finalB:alin0 a%#ir
;an ti;a% ;a:at ;i0an00/ 0/0at
ATTACHMENT 1
P#.-B,(%&"&'(*&o) Do',0.)* C Fo#0/
ADMINISTRATIE REQUIREMENT
Eli0i9le A::liant intereste; to atten; t#e :re'=/alifiation :ro:osal s#o/l; atta# t#e o:ies of le0al
a;5inistration ;ata, as follo!s+
1. For5 ($( State5ent LetterB Surat Pernyataan
2. For5 ($* Delaration of Un;erta%in0
3. List of Fir5Hs S#are#ol;er an; Aoar; of DiretorB Daftar Pemegang Saham dan Susunan Pengurus
Perusahaan
4. Co:ies of ID Car; of Me59er of AoD an; AoC 5e59er of t#e Co5:anyB Copy KTP dari Dewan Direksi
dan Dewan Komisaris Perusahaan
5. Artile of Assoiation of Co5:any !#i# alrea;y in line !it# La! No$ -) year *))" re+ Li5ite; Lia9ilities
an; its latest a5en;5en;Bnggaran Dasar Perusahaan yang te!ah sesuai dengan "" #o. 4$ Tahun 2$$%
mengenai Perseroan Ter&atas dan kte Peru&ahan Terakhir
'. Co5:any @/alifiation Certifiate 0ra;e EB" Sertifikat K!asifikasi (o!ongan ' atau %
%. Ta2 Payer Re0istration N/59er B #omor Pokok )a*i& Pa*ak +#P)P,
-. Co:y of Co5:any Latest Ta2 Pay5ent BSurat Pem&eritahuan Tahunan Pa*ak +SPT, Terakhir
.. Ta/a&!e 0ntrepreneur Confirmation 1etter2 Surat Pengukuhan Pengusaha Kena Pa*ak +SPPKP,
1$. Certifi3ate of Ta/ 4egistered 2Surat Keterangan Terdaftar +SKT,
11. Tra;e A/siness Liense or Constr/tion Ser<ie A/siness Liense M BSurat 5*in "saha Perdagangan +S5"P,
atau Surat i*in "saha 6asa konstruksi+S5"6K,
12. Certifiate of Co5:any Re0istrationB Tanda Daftar Perusahaan +TDP,
13. Co5:anyNs Do5iile Re0istrationB Keterangan Domisi!i Perusahaan
14. Ann/al Cor:orate Ta2 Ret/rn for t#e 3 .t#ree1 latest year B Surat Pem&eritahuan Tahunan Pa*ak
Penghasi!an 7adan2 SPT PPh 7adan 3 +tiga, tahun terakhir
15. E=/i:5ent list
1'. Si5ilar Pro>et Referene +Design and 7ui!d )TP with 3apa3ity minimum 12$$ !ps8 a&!e to treat water with
high f!u3tuated and tur&idity8 ammonium8 iron8 manganese and detergent 3ontent,
Re5ar%s+ Co:y s#all 9e le0aliLe; 9y its orres:on;in0 iss/in0 a0eny
FORM 1.1
<Co0$()7 L.**.# H.(1=
STATEMENT LETTER
To+ !&11&)2 Co00&**.. PT PAM L7o))(&//. J(7(
+()*o# P,/(*5 G.1,)2 S.)*#(% S.)(7() I5 L()*(& 95
J%. A/&( A"#&-( No : S.)(7() J(-(#*( 10290 ; INDONESIA5
T.%$: 021-8924410<4,)*&)2=5 "(>: 021-89244?2
Dear Sirs,
($ 4e #ere9y a::ly .as Ostate o5:anyNs na5esP1 to 9e t#e ten;er for PESANGGRAHAN 4ATER
TREATMENT PLANT PROJECT$
*$ 4e a/t#oriLe t#e Ten;er Co55ittee or its a/t#oriLe; re:resentati<e to on;/t any in<esti0ation to <erify
t#e state5ents ;o/5ents an; infor5ation s/95itte; an; to larify any infor5ation of t#is A::liation$ For
t#is :/r:ose, !e #ere9y a0ree to f/rnis# :ertinent infor5ation ;ee5e; neessary or re=/este; 9y t#e Ten;er
Co55ittee to <erify state5ents an; infor5ation :ro<i;e; in t#is a::liation or re0ar;in0 o/r o5:etene
an; stan;in0$
3$ T#e na5es an; :ositions of :ersons, !#o 5ay 9e ontate; for f/t/re infor5ation, if re=/ire; are as
follo!s+
Na5e B Position +
A;;ress +
Tele:#oneBfa2 +
E'5ail +
-$ 4e a0ree t#at t#e Ten;er Co55ittee #as t#e ri0#t to !ai<e any o5:laints fro5 A::liants$
,$ 4e a0ree to s/95it t#e 9i; if =/alifie;$
E$ 4e ;elare t#at t#e state5ents 5a;e #erein an; t#e infor5ation :ro<i;e; in t#is a::liation are o5:lete,
tr/e an; orret in e<ery ;etail
"$ 4e a0ree t#at PAL?JA #a<e t#e ri0#t to anel t#e PO an;Bor Contrat if PAL?JA ;iso<er in<ali; le0al
;ata :ro<i;e; 9y /s$ An; PAL?JA !ill not #a<e t#e o9li0ation to :ro<i;e any e2:lanationBan; or ;o/5ent
e2:lainin0 s/# in<ali;ity to /s$
Res:etf/lly, R:$E,))) ;/ty
sta5: an; si0ne;
Si0nat/re QQQQQQQQQQQQQQ
Na5e QQQQQQQQQQQQQQQQQ
Position Presi;ent Diretor state in Dee; of
Notary a9o/t t#e latest list of Aoar;
of Diretor of t#e Co5:any
FORM 1.2.
Co5:any Letter Hea;
PA+TA INTEGRITAS
Saya yan0 9ertan;a tan0an ;i 9a!a# ini, ;ala5 ran0%a :en0a;aan 9aran0B>asa /nt/% :e%er>aan $$$$$$$$PRO?EK
INSTALASI PENGOLAHAN AIR PESANGGRAHAN$$$$$$$$$$$$$$$$$$$$$$$$$$:a;a PT PAM Lyonnaise Jaya .PAL?JA1
;en0an ini 5enyata%an 9a#!a saya +
($ ti;a% a%an 5ela%/%an :ra%te% %or/:si, %ol/si ;an ne:otis5e .KKN1,
*$ a%an 5ela:or%an :a;a :i#a% yan0 9er!a>i9 B 9er!enan0 a:a9ila 5en0eta#/i a;a in;i%asi KKN ;ala5
:roses :en0a;aan ini,
3$ Aerse;ia ;en0an %e5a5:/an saya /nt/% 5e59eri%an 9ant/anB;/%/n0an %e:a;a :en0/n0%a: B sa%si yan0
5enyan0%/t ;en0an :en0/n0%a:an a;anya :ra%te% s/a:, KKN ata/:/n yan0 se>enis ;i 9a!a# !e!enan0
saya
-$ a%an 5eneri5a se0ala %e:/t/san yan0 ;itera:%anB;ila%/%an ole# PAL?JA se#/9/n0an ;en0an :roses
ten;er ini
,$ seara trans:aran 5enyata%an 9a#!a ti;a% 5en0a;a%an se0ala 9ent/% %er>asa5a ata/ %onsorsi/5 ;en0an
:i#a% :enye;ia 9aran0B>asa lainnya yan0 9er:artisi:asi ;ala5 ten;er ini
E$ 9er>an>i a%an 5ela%sana%an t/0as seara 9ersi# , trans:aran ;an :rofesional ;ala5 arti a%an 5en0era#%an
se5/a %e5a5:/an ;an s/59er ;aya seara o:ti5al /nt/% 5e59eri%an #asil %er>a ter9ai% 5/lai ;ari
:enyia:an :ena!aran, :ela%sanaan ;an :enyelesaian :er%er>aanB%e0iatan ini
"$ 9erse;ia ;i%ena%an san%si 5oral, san%si a;5inistrasi serta ;it/nt/t 0anti r/0i seara :er;ata ;anBata/
:i;ana ses/ai ;en0an %etent/an :erat/ran :er/n;an0'/n;an0an yan0 9erla%/ a:a9ila saya 5elan00ar #al'
#al yan0 tela# saya nyata%an ;ala5 :a%ta inte0ritas ini$
Te5:at, $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ *)(-
Penye;ia 9aran0B>asa
9 TTD diatas :aterai 4p. '$$$89
9 Cap perusahaan
Na5a Dire%t/r Peserta yan0 terant/5 ;ala5 A%ta Notaris tera%#ir 5en0enai s/s/nan De!an Dire%si
COMPANY CAPA!ILITIES
($ For5 *$(+ General Infor5ation
*$ Co5:any Profile
3$ For5 *$*+ Co5:any E2:eriene
-$ Finanial Ca:a9ility
,$ Ot#er S/::ortin0 Do/5ents
FORM 2-1
1. GENERAL INFORMATION
1. Co0$()7 N(0. +
A::liant Position + 1ead Company24epresentati;e2:em&er2Su&3ontra3tor et3.
A;;ress +
Tele:#one +
Fasi5ile +
E'5ail +
Contat Person +
Position +
Tele:#one +
Fasi5ile +
E'5ail +
2. Co0$()7 N(0. +
A::liant Position + 1ead Company24epresentati;e2:em&er2Su&3ontra3tor et3.
A;;ress +
Tele:#one +
Fasi5ile +
E'5ail +
Contat Person +
Position +
Tele:#one +
Fasi5ile +
E'5ail +
O :lease a;; ot#er :artners as a::ro:riate P
Re5ar%s+
A le0aliLe; o:y of Co5:any Dee; of Inor:oration of Aran# Offies or any >/stifie; e<i;ene if any, s#all 9e
atta#e;
2. COMPANY PROFILE
1. MANPOWER RESOURCES
4rite na5e, :osition, fiel; of st/;y, e;/ation le<el an;Bor :rofessional ertifiation of %ey :ersonnel an;
s/::ortin0 staff of t#e o5:any$
2. ORGANIDATION CHART
In;iate an or0aniLation #art !it# a ;esri:tion of !or% ;i<ision of t#e :ro>et, !#i# t#e A::liant is :lannin0
to e2e/te$
Atta# an or0aniLation #art larifyin0 a 9a%'/: ser<ies relations#i: 9et!een t#e Lea; Co5:any an; loal
re:resentati<e offie .if a::lia9le1 as to !#i# setion of t#e a::liant is f/lly res:onsi9le for s/::ly of t#e
e=/i:5ent an; also relate; 9a%/: ser<ies inl/;in0 t#e loal !or%s#o:Bloal a0ent$
Re5ar%s+
Do/5ent e<i;enin0 <ali;ity of t#e a9o<e infor5ation 5ay ta%e 5any for5s, if sin0le ;o/5ent is onsi;ere;
/nsatisfatory, t#e A::liant is free to :ro<i;e 5ore t#an oneB<ario/s s/::ortin0 ;o/5ents
FORM 2-2
?. COMPANY EEPERIENCE
1 2 ? 4 8 F 9 :
No T7$. EB,&$0.)*/Wo#-/
S,$$%&.1
C%&.)* Co)*#('*
A(%,./
D,#(*&o)
'o0$%.*&o)
A'*&)2
A/
P#o3.'*
Lo'(*&o)/
1./*&)(*&o)
R.0(#-/
Instr/tion to fill For5+
Col/5n * + Please fill !it# ty:e of 5a>or e=/i:5entB4or%s s/::lie; 9y A::liant for t#is Contrat
Col/5n 3 + Please fill !it# t#e Pro>et na5e, Pro>et O!nerBClient
Col/5n - + Contrat <al/e .only :ro>et fro5 t#e :ast " years onsi;ere;1
Col/5n , + Co5:letion ;ate of Contrat$
Col/5n E + Atin0 as 5ain ontrator, s/9 ontrator, s/9 ontrator or :artner in >oint o:eration
Re5ar%s+
- S/::ortin0 e<i;ene >/stifyn0 <ali;ity of a9o<e 5entione; Contrat 5ay9e re=/este; 9y t#e :/r#aser$
- Do/5ent e<i;enin0 <ali;ity of A::liant e2:eriene 5ay ta%e 5any for5s, if sin0le ;o/5ent is
onsi;ere; /nsatisfatory, t#e A::liant is free to :ro<i;e 5ore t#an <ario/s s/::ortin0 ;o/5ents
4. FINANCIAL CAPA!ILITY
($ T#e A::liant s#all s/95it a/;ite; finanial re:ort .9alane s#eets an; ino5e state5ent1 for t#e last ,
.fi<e1 years, si0ne; 9y re0istere; P/9li Ao/ntant$
*$ Line of Cre;it$ Unon;itional state5ent of Line of Cre;it fro5 re:/ta9le Aan%$
8. OTHER SUPPORTING DOCUMENTS
T#e A::liant is free to f/rnis# any ot#er a;;itional infor5ation s/# as :/9lis#e; o5:any :rofile, :ro5otional
9oo%let, et$ t#at 5ay i5:ro<e o<erall assess5ent on o5:any re:/tation F i5a0e$