1-26-07065 Design-Build Request for Qualifications Clinic Space at 2050 Mass Final.pdf

REQUEST FOR QUALIFICATION

STATEMENTS

FROM DESIGN-BUILD ENTITIES

FOR THE

AMBULATORY PRIMARY CARE OUTPATIENT CLINIC SPACE AT

2050 MASSACHUSETTS

SAN BERNARDINO COMMUNITY WELLNESS CENTER

DBRFQu 26-07065

10801 6th Street Rancho Cucamonga, CA 91730

Publish: April 15, 2026 Mandatory RFQu Conference: April 29, 2026, 10:00 AM Last Day for Questions: May 13, 2026 Submittal Deadline: May 27, 2026, 2:00 PM

Clinic Space San Bernardino CWC Request for Qualification Statements from Design-Build Entities

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TABLE OF CONTENTS

NOTICE OF QUALIFICATION REQUIREMENT AND COMPETITIVE SELECTION

PROCESS

1. GENERAL DESCRIPTION OF THE PROJECT

2. GENERAL STATEMENT OF QUALIFICATION CRITERIA AND PRIORITIES

3. A DESIGN-BUILD ENTITY DEFINED

4. COMPETITIVE SELECTION PROCESS

5. ANTICIPATED PROJECT SCHEDULE

6. QUALIFICATION REQUIREMENTS

7. QUALIFICATION PROCEDURE

8. MANDATORY RFQu CONFERENCE

9. QUALIFICATION REVIEW AND NOTIFICATION PROCESS

10. ANTICIPATED QUALIFICATION SCHEDULE

11. CONFLICTS OF INTEREST

12. RIGHTS RESERVED BY IEHP

EXPLANATION OF SCORING FRAMEWORK

PART I: INFORMATION ABOUT THE D-B ENTITY AND EACH OF ITS CORE TEAM

MEMBERS

PART II: ESSENTIAL REQUIREMENTS FOR THE DESIGN-BUILD ENTITY AS A

WHOLE

PART III: SCORED QUESTIONS FOR INDIVIDUAL MEMBERS OF THE D-B ENTITY

AND CORE ORGANIZATIONS

PART IV: RELEVANT EXPERIENCE

PART V: VERIFICATION

INSTRUCTIONS FOR QUALIFICATION SUBMISSION

QUALIFICATION QUESTIONNAIRE

PART I I ESSENTIAL REQUIREMENTS

PART III SCORED QUESTIONS FOR MEMBERS OF THE D-B ENTITY AND CORE

ORGANIZATIONS

PART IV RECENT CONSTRUCTION PROJECTS COMPLETED

PART V CERTIFICATION

SCORING WORKSHEETS

DETAILED SCORING WORKSHEETS

EVALUATION SUMMARY

ATTACHMENTS

EXHIBIT A – BRIDGING DOCUMENTS

EXHIBIT B – SKILLED AND TRAINED WORKFORCE CERTIFICATION

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NOTICE OF QUALIFICATION REQUIREMENT

AND COMPETITIVE SELECTION PROCESS

Inland Empire Health Plan (“IEHP”) hereby gives notice that it intends to request competitive proposals for Design-Build services for the Ambulatory Primary Care Outpatient Clinic Space at San Bernardino Community Wellness Center (“Project”), and that IEHP has determined that Design-Build Entities must be qualified prior to submitting a proposal.

Qualification Statements must be submitted no later than: May 27, 2027, 2:00PM

1. GENERAL DESCRIPTION OF THE PROJECT

The purpose of the Project is to design and construct an Ambulatory Primary Care Outpatient Clinic space. The total project, including construction and design, is estimated to cost approximately $2,000,000.00.

This Project is strictly limited to an ambulatory, primary-care, outpatient clinic setting. The facility will not include urgent care, emergency care, inpatient services, surgical suites, imaging modalities requiring radiation shielding (X-ray/CT/MRI), or any functions governed by inpatient or acute-care regulatory standards. All design elements must align with outpatient, non-acute clinical workflow and primary-care service delivery.

Included clinical uses:

• Preventive and wellness care

• Chronic disease management

• Care coordination

• Patient education and support spaces

Excluded clinical uses:

• Inpatient care or overnight stays

• Emergency services

• High-acuity treatment rooms

• Imaging requiring shielding

• OSHPD-1 regulated spaces

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• Behavioral health crisis stabilization The Project will consist of the design and construction of a clinic space including:

o Design: A design that will draw inspiration from hospitality environments rather than traditional clinical settings.

o Atmosphere: Welcoming, professional, and calming, with intuitive layouts that reduce stress and promote dignity.

o Materials: Warm, natural finishes such as wood, stone, and soft upholstery to create a non-institutional feel.

o Lighting: Abundant natural light complemented by layered ambient and task lighting for comfort and safety.

o Biophilic Elements: Incorporate greenery and nature-inspired textures to enhance well-being.

o Wayfinding: Clear, accessible signage and visual cues for easy navigation.

o Brand Integration: Care Division color palette with accent tones that evoke warmth and innovation.

o Sustainability: Low-VOC finishes, recycled content, and energy-efficient systems to meet environmental goals.

o Clinical Scope Confirmation: All program spaces must be designed solely for outpatient primary-care service delivery; no acute-care or emergent-care functions may be incorporated.

The Project site lies at 2050 Massachusetts Avenue, San Bernardino, CA. Project site is more specifically depicted in the Bridging Documents, attached hereto as Exhibit A and incorporated herein by this reference.

2. GENERAL STATEMENT OF QUALIFICATION CRITERIA AND PRIORITIES

Design-Build Entities should include staff members with the following qualifications:

▪ For Design:

▪ Design-build experience with projects similar to the Project in size, scope, type, complexity and cost of the Project is preferred

▪ Experience specifically with ambulatory, primary-care outpatient clinic environments (non‑acute), including workflow planning, patient‑centered design, DBRFQu-PW-26-07065 Design-Build Request for Qualifications (Public Works) Rev 4-29-24

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▪ Experience working with the Contractor included in the Design-Build Entity

▪ Experience obtaining the permits and regulatory approvals required for the Project.

▪ Familiarity with outpatient clinical space requirements (e.g., exam rooms, consult rooms, patient flow, accessibility standards) and not OSHPD‑1 inpatient or acute-care requirements.

▪ For Construction:

▪ California Class (B) General Building Contractor License

▪ Design-build experience with projects similar in size, scope, type, complexity and cost of the Project is preferred

▪ Experience constructing ambulatory outpatient clinic spaces, including medical office exam areas, non‑acute clinical finish standards, ADA compliance, and mechanical/electrical systems appropriate to outpatient care (not acute or inpatient systems).

▪ Experience working with the Engineer-of-Record included in the Design-Build Entity

3. A DESIGN-BUILD ENTITY DEFINED

A Design-Build Entity (“D-B Entity”) is defined as “a partnership, corporation, or other legal entity that is able to provide appropriately licensed contracting, architectural, and engineering services as needed pursuant to a design-build contract.”

IEHP will consider teams consisting of a general contractor with contractual relationships with entities providing the other required licenses and capable of providing all services required for the Project as an ambulatory, primary‑care outpatient clinic.

For purposes of qualification, each D-B Entity must identify and provide information for certain Core Organizations, which include the General Contractor and Engineer of Record.

These Core Organizations must individually complete the appropriate scored-question portions of the Qualification Questionnaire and obtain a passing score in order for the D-B Entity as a whole to be qualified. Failure to provide the appropriate completed portions of the questionnaire from all required Core Organizations may result in determination of not qualified.

If the D-B Entity chooses to use an entity with the capability of performing both design and construction services (e.g., a subcontractor with a licensed engineer and design staff), then

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IEHP reserves the right to specify additional requirements for subcontractors or sub-consultants in the Request for Proposals for the Project.

4. COMPETITIVE SELECTION PROCESS

IEHP envisions respondents to consist of teams of consultants, design professionals and contractors that collectively possess all of the experience required to perform the entire Project. IEHP plans to select a D-B Entity for the Project through a two-step competitive selection process:

• with emphasis on demonstrated experience delivering non‑acute, ambulatory primary‑care outpatient environments.

• with evaluation priority given to teams who understand outpatient clinic operational needs, patient flow, and applicable outpatient code/permit requirements.

▪ Step 1: Qualification Phase of responsible and qualified D-B Entities

▪ Mandatory RFQu Conference: April 29, 2026, at 10:00am. (Closed-toe shoes or boots are required.)

o Location: 2050 Massachusetts San Bernardino 92405

▪ Interested D-B Entities submit Statement of Qualifications by May 27, 2026, 2:00

PM

▪ IEHP determines the list of Qualified Design-Build Entities

Only the D-B Entities that are listed in the Qualified Proposers List at the conclusion of Step 1 (meet the minimum requirements and score at or above the established minimum threshold) will be invited to participate in Step 2. IEHP intends to award the contract on a competitive “Best Value” basis, consistent with the evaluation methodology and final selection procedure identified in this RFQ and RFP.

▪ Step 2: Proposal Phase during which IEHP will consider proposals and pricing submitted by qualified D-B Entities.

5. ANTICIPATED PROJECT SCHEDULE

Event Approximate Date Qualification Statements Due May 27, 2026, 2:00 PM

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IEHP identifies and invites qualified D-B Entities to prepare proposals based on D-B contract documents

June 3, 2026

Proposals and Pricing for Design Services due June 24, 2026

Contract Award July 8, 2026

6. QUALIFICATION REQUIREMENTS

It is mandatory that all interested D-B Entities submit a complete Qualification Statement, including a completed Qualification Questionnaire, the required Skilled and Trained Workforce Certification, attached hereto as Exhibit B and incorporated herein by this reference, and ALL additional requested materials, for IEHP’s review and evaluation. In order to be deemed qualified by IEHP and be listed on the final Qualified Proposers List for the Project, a D-B Entity must pass each section/subpart and be qualified by meeting all minimum qualification criteria and section minimum scores. All Design-Build entities meeting the minimum required criteria and section minimum scores will be included on the Qualified Proposers List and will be eligible to submit a Proposal. IEHP shall identify at least three qualified proposers, if feasible, in accordance with PCC §22164(f)(3).

Qualification Statements that fail to include ALL of the requested information, present false or misleading information, or are not submitted in the format requested may be considered nonresponsive and rejected on that basis.

While the Qualification Questionnaire and required attachments are intended to assist IEHP in determining qualification and responsibility prior to submittal of proposals, IEHP reserves the right to utilize information from other sources in its qualification evaluation of D-B Entities. IEHP’s qualification determinations will be based on objective evaluation criteria.

However, neither the determination that a D-B Entity is qualified, nor any qualification rating, will preclude IEHP from additional post-proposal consideration and determination of whether a proposer has demonstrated the requisite trustworthiness, quality, fitness, capacity and experience to be eligible for award of the Design‑Build Contract for this ambulatory primary‑care outpatient clinic Project.

7. QUALIFICATION PROCEDURE

IEHP has based the Qualification Questionnaire on model qualification documents prepared by the California Department of Industrial Relations. Accordingly, the qualification procedure described herein: (1) requires a standardized Qualification Questionnaire,

(2) adopts and applies a uniform system for rating Design-Build Entities on objective criteria, and (3) creates an appeals procedure by which a D-B Entity that is found to be not qualified may dispute that determination.

Except for the Contact Information section (subpart I.A) of the Qualification Questionnaire, which will be considered a public record, all completed Qualification Questionnaires and

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IEHP may disclose such materials only to the extent necessary for verification, investigation, or appeal proceedings.

IEHP reserves the right to provide qualification materials to third parties solely for such purposes.

8. MANDATORY RFQu CONFERENCE

A mandatory conference to discuss this RFQu and answer questions from prospective D-B Entities prior to qualification submittal will be held in open forum on April 29, 2026, 10:00 AM at 2050 Massachusetts, San Bernardino, CA 92405.

Attendance at the meeting by a representative of the D-B Entity is a prerequisite for submitting a Qualification Statement, and failure to attend shall result in disqualification.

9. QUALIFICATION REVIEW AND NOTIFICATION PROCESS

The completed Qualification Questionnaire with required attachments must be submitted by the deadline specified. Once received, IEHP will review and notify the D-B Entities as follows:

a. Receipt: The original Qualification Questionnaire with required attachments will be stamped upon receipt with an official date and time of receipt.

b. Completeness Review: Each qualification submission will be reviewed for completeness by IEHP staff within ten (10) business days from the deadline date. The D-B Entity will then be notified as to completeness (by telephone, facsimile, or electronic mail, at IEHP’s discretion). IEHP staff may request additional information and if such request is made, the D-B entity will have three (3) business days from such notification to submit the requested information and the time limits for Staff Review and Qualification Notification shall be adjusted accordingly.

c. Staff Review: Each complete Qualification Questionnaire with all required attachments will be reviewed by IEHP staff within twenty (20) business days from the submission deadline date.

d. Qualification Notification: Each D-B Entity will be notified of its qualification rating by certified mail within twenty-five (25) business days from the submission deadline date.

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A D-B Entity must meet the minimum requirements for qualification for consideration. In addition, all D-B Entities meeting the minimum requirements will be ranked according to the Total Score rating. IEHP shall determine whether each D-B Entity meets the minimum required scores for each section. All entities meeting the minimum section scores shall be included on the Qualified Proposers List, and IEHP shall identify at least three (3) qualified proposers, if feasible, consistent with PCC §22164(f)(3). All D-B Entities listed on the Qualified Proposers List will be notified when the Request for Proposal documents are issued.

If the D-B Entity is rated as “Not Qualified” for the Project, it may appeal the determination in accordance with the appeal procedure set forth herein.

10. ANTICIPATED QUALIFICATION SCHEDULE

The following is the anticipated schedule of events for this Qualification process:

Action Date

Mandatory RFQu Conference April 29, 2026, 10:00 AM

Written Questions Due not later than May 13, 2026, 4:00 PM

Qualification Statement Submission Deadline not later than May 27, 2026, 2:00 PM

IEHP reserves the right to extend the deadline for submittal of Qualification Submittals and related materials. If it chooses to exercise this right, it will do so through a written addendum. All persons or entities will be notified on the Bonfire website.

11. CONFLICTS OF INTEREST

No architect or engineer retained by IEHP who assists in the development of pre-proposal Project-specific documents may participate in any D-B Entity in the preparation of a proposal for the Project.

12. RIGHTS RESERVED BY IEHP

IEHP may deny qualification where the requested information and materials are not provided, or not provided by the date specified. There is no appeal from a denial due to an incomplete or late submittal.

IEHP reserves the right to accept qualification submittals despite minor irregularities and omissions in the information that could disqualify a D-B Entity. IEHP reserves the right to make all final qualification determinations and to determine at any time that the qualification procedures will not be applied to the Project.

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IEHP reserves the right to verify all submitted information.

IEHP may reject any Qualification Statement that contains errors, omissions, or inconsistencies that materially affect responsiveness

IEHP reserves the right to adjust, increase, limit, suspend or rescind a D-B Entity’s qualification rating based on subsequently-acquired information. D-B Entities whose rating changes sufficient to disqualify them will be notified and given an opportunity for an appeals process consistent with the procedures for appealing an initial qualification determination.

IEHP reserves the right to modify, suspend, or cancel this Project, including the qualification phase, in whole or in part, at any time and at its sole discretion. The Design-Build Entity will be solely responsible for the costs of preparing the qualification materials and participating in the qualification process.

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E x p la n a ti o n o f

S c o ri n g F ra m e w o rk

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EXPLANATION OF SCORING FRAMEWORK

The qualification determination for a D-B Entity will result from consideration of the scores attained in all parts of the Qualification Questionnaire.

In addition to attaining scores at or above the specified minimums for each Section and/or subpart, the scores for each subpart in Part III and Part IV will be combined to calculate a “Total Score.” All D-B Entities that achieve the minimum required section scores will be included on the Qualified Proposers List. IEHP shall identify at least three qualified proposers, if feasible, in accordance with PCC §22164(f)(3). Total Score rankings may be used for evaluation and reference but shall not be used to limit the Qualified Proposers List to fewer than all entities meeting the minimum required section scores. All qualified D‑B Entities may be ranked based on Total Score for evaluation purposes, but ranking shall not be used to limit the Qualified Proposers List to only three entities.

PART I: INFORMATION ABOUT THE D-B ENTITY AND EACH OF ITS CORE TEAM

MEMBERS

Part I applies to the D-B Entity as a whole and to each of its Core Organizations, and is for identification purposes only. There is no scoring value to this portion of the Qualification Questionnaire.

Note: Subpart I.A is the only public record portion of the Qualification Questionnaire.

PART II: ESSENTIAL REQUIREMENTS FOR THE DESIGN-BUILD ENTITY AS A WHOLE

Part II applies to the D-B Entity as a whole and to each of its Core Organizations, and consists of a series of pass/fail qualification questions. All questions must receive a “Pass” or the D- B Entity may be disqualified with no consideration given to the remainder of the Qualification Questionnaire.

PART III: SCORED QUESTIONS FOR INDIVIDUAL MEMBERS OF THE D-B ENTITY AND

CORE ORGANIZATIONS

Part III includes a series of questions that must be answered, each of which has an established numerical score (as indicated in the Scoring Worksheet provided herein). The D-B Entity must attain scores at or above the specified minimums for each subpart in order for the D-B Entity to be deemed qualified.

Subpart III.A: Scored Questions for the General Contractor

Subpart III.A applies to the General Contractor. A minimum score of 125 points must be attained for the General Contractor or the D-B Entity will not be deemed qualified.

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Subpart III.B: Scored Questions for the Engineer of Record

Subpart III.B applies to the Engineer of Record. A minimum score of 49 points must be attained for the Engineer of Record or the D-B Entity will not be deemed qualified.

PART IV: RELEVANT EXPERIENCE

Part IV requires the D-B Entity to submit information regarding recently-completed projects that are of similar size, type, and complexity. Projects demonstrating experience with non‑acute, ambulatory outpatient clinical environments will be given relevance in determining similarity. IEHP will have sole discretion to determine which projects are similar to the Project in size, type, and complexity. The responses will be scored (as indicated in the sample Scoring Worksheet provided herein). The D-B Entity must attain scores at or above the specified minimums for each subpart in order for the D-B Entity to be deemed qualified.

Subpart IV.A: Relevant Experience of the General Contractor

Subpart IV.A applies to the General Contractor. A Minimum score of 16 points must be attained for the General Contractor or the D-B Entity will not be deemed qualified.

Subpart IV.B: Relevant Experience of the Engineer of Record

Subpart IV.B applies to the Engineer of Record. A Minimum score of 12 points must be attained for the Engineer of Record or the D-B Entity will not be deemed qualified.

PART V: VERIFICATION

Part V requires verification under oath by the D-B Entity and each Core Organization in a manner consistent with the verification requirements for civil pleadings pursuant to Code of Civil Procedure section 446. IEHP will not review Qualification Questionnaires that are not properly verified.

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In s tr u c ti o n s f o r

Q u a li fi c a ti o n

S u b m is s io n

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INSTRUCTIONS FOR QUALIFICATION SUBMISSION

Each Qualification Questionnaire must be signed under penalty of perjury in the manner designated on the Certification page (Part V), by an individual who has the legal authority to bind the D-B Entity and each Core Organization on whose behalf that person is signing.

If any information provided by a D-B Entity or Core Organization becomes inaccurate, the D- B Entity must immediately notify IEHP and provide updated accurate information in writing, under penalty of perjury.

Requested information must be provided on the Qualification Questionnaire forms provided. To the extent that additional space is required in order to fully and completely answer any question the submitting firm should note in the Questionnaire that additional information is being submitted. Submit such information on the company letterhead of the firm submitting the Questionnaire with reference to: (a) the Project, (b) the relevant subpart and question, and (c) the Questionnaire page number for which the information is being provided.

Qualification Questionnaires must be submitted on the Euna (Bonfire) Website at http://iehp.bonfirehub.com.

Submittal Deadline: May 27, 2026, 2:00 PM

Respondents shall assume full responsibility for timely delivery to the Bonfire submission portal. ORAL, TELEPHONIC, FACSIMILE, TELEGRAPHIC, OR E-MAILED QUALIFICATION

QUESTIONNAIRES ARE INVALID AND WILL NOT BE ACCEPTED.

NO QUALIFICATION DOCUMENTS WILL BE ACCEPTED AFTER THE DUE DATE AND TIME

unless IEHP determines that it is in its best interest to reopen the qualification process.

All submissions must be uploaded and time‑stamped within the Bonfire system by the designated deadline. The Bonfire timestamp shall be the sole and official timepiece for determining submission compliance. IEHP will not consider local device clocks, email timestamps, or any other time source for compliance purposes.

Incomplete, partially uploaded, or corrupted files will be considered non-responsive.

Respondents are strongly encouraged to allow sufficient time for upload and confirmation within the Bonfire system.

http://iehp.bonfirehub.com/

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P re

-Q u a li fi c a ti o n

Q u e s ti o n n a ir e

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CONTRACTOR PRE-QUALIFICATION QUESTIONNAIRE

A. CONTRACTOR INFORMATION

(All Questions Must Be Answered)

Firm Name (as it appears on CSLB license):

Firm Type (Select one): Corporation LLC Partnership Sole Proprietorship Joint Venture

Contact Person/Title:

(List Owner(s) if Firm is a Sole Proprietorship or Partnership)

Local Address (P.O. Box is not acceptable):

Address 1:

Address 2:

City

Zip:

Office Telephone:

Contact Mobile:

Fax Number:

E-mail Address:

List all California construction or other professional license numbers, classifications and expiration dates held by your firm:

License Number Classification Expiration Date

List your firm’s DIR Public Works Contractor (PWCR) Registration Number(s):

PWCR Number Entity Name Expiration Date

If any of your firm’s license(s) are held in the name of a corporation, limited liability company, or partnership, list below the names of the qualifying individual(s) listed on the CSLB records who meet(s) the experience and examination requirements for each license.

License Number Qualifying Individual Expiration Date

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B. CURRENT ORGANIZATION AND STRUCTURE

Complete the section below for the appropriate type of firm:

For Firms That Are Corporations:

1a. Date incorporated:

1b. Under the laws of what state:

1c. Provide all the following information for each person who is either (a) an officer of the corporation (president, vice president, secretary, treasurer), or (b) the owner of at least ten percent of the corporation’s stock:

Name Position Years with Firm

Ownership

1d. Identify every construction firm that any person listed above has been associated with (as owner, general partner, limited partner or officer) at any time during the last five years.

NOTE: For this question, “owner” and “partner” refer to ownership of ten percent or more of the business, or ten percent or more of its stock, if the business is a corporation.

Person’s Name Construction Firm Date of Person’s

Participation

For Firms That Are Limited Liability Companies (LLC):

1a. Date Article of Organization filed:

1b. Under the laws of what state:

1c. Provide all the following information for all members of the LLC:

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Participation with Firm

For Firms That Are Partnerships:

1a. Date incorporated:

1b. Under the laws of what state:

1c. Provide all the following information for each partner who owns ten percent or more of the firm.

Participation with

Firm

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For Firms That Are Sole Proprietorships:

1a. Date of commencement of business

1b. Identify every construction firm that the business owner has been associated with (as owner, general partner, limited partner or officer) at any time during the last five years.

NOTE: For this question, “owner” and “partner” refer to ownership of ten percent or more of the business, or ten percent or more of its stock, if the business is a corporation.

Participation with

Firm

For Firms That Intend to Make a Bid as Part of a Joint Venture:

1a. Date of commencement of joint venture:

1b. Provide all the following information for each firm that is a member of the joint venture that expects to bid on one or more projects

Name of Construction Firm % Ownership

Note: Explain on a separate sheet. Provide all other pertinent information required in the sections above, for each Corporation, LLC, Partnership, or Sole-Proprietorship that is a part of the Joint Venture.

FOR ALL FIRMS:

2. At any time during the past five years, has your firm shared office space, warehouse space, yard, plant or shop facilities, staff, equipment, telecommunications or other assets with any other construction firm? (If yes, identify and explain below.)

Construction Firm Description of Sharing

Agreement

Location of

Facilities

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3. State your firm’s gross revenues for each of the last three fiscal years:

Current year ($):

Previous year ($):

Year prior to previous year ($):

4. How many years has your firm been in business in California as a contractor under your present business name and license number?

5. Bonding Capacity – Provide documentation from your surety identifying the following:

Name of Bonding Company/Surety:

Name of Surety Agent:

Address:

Telephone number:

6. If your firm was required to pay a premium of more than one percent for a performance and payment bond on any project(s) on which your firm worked at any time during the last three years, state the percentage that your firm was required to pay. You may provide an explanation for a percentage rate higher than one percent, if you wish to do so.

7. List all other sureties (name and full address) that have written bonds for your firm during the last five years, including the dates on which they were issued:

Name Address Date

8. How often do you require documented safety meetings to be held for construction employees and field supervisors during the course of a project?

9. List your firm’s Experience Modification Rate (EMR) (California workers’ compensation insurance) for each of the past three premium years:

Current year rate:

Previous year rate:

Year prior to previous year rate:

10. Does your firm regularly utilize a third party consultant to review labor compliance documents of subcontractors on a public works project? Yes No

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11. Provide the name, address and telephone number of the apprenticeship program (approved by the California Apprenticeship Council) from whom you intend to request the dispatch of apprentices to employ on any public works project awarded by [Public Entity].

Name Address Phone

12. Provide the name, address and telephone number of the apprenticeship program (approved by the California Apprenticeship Council) from whom you have requested and/or employed apprentices in the past three years.

Name Address Phone

13. If your firm operates its own State-approved apprenticeship program:

(a) Identify the craft or crafts in which your firm provided apprenticeship training in the past year;

(b) State the year in which each such apprenticeship program was approved and attach evidence of the most recent California Apprenticeship Council approval(s);

(c) For each craft, list the number apprentices employed by your firm and the number of individuals that completed apprenticeships while employed by your firm during the last three years.

Craft Year No. Apprentices No. Completed

14. Has your firm changed names or license number in the past five years?

(If yes, explain on a separate sheet, including the reason for the change.)

Yes No

15. Has there been any change in ownership of your firm at any time during the last five years?

(If yes, explain on a separate sheet.)

Yes

No

NOTE: A corporation whose shares are publicly traded is NOT required to answer this question.

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16. Is your firm a subsidiary, parent, holding company or affiliate of another construction firm? Yes No

(If yes, explain on a separate sheet.)

NOTE: Include information about other firms if one firm owns 50 percent or more of another, or if an owner, partner, or officer of your firm holds a similar position in another firm.

17. Has any owner, partner and/or officer of your firm operated or been connected to a construction firm under any other name in the last five years not listed in Section A or

Section B above at any time in the past five years? Yes No

(If yes, provide the person’s name, construction firm name, and dates of participation.)

Name Construction Firm Dates of

Participation

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C. ESSENTIAL CRITERIA QUESTIONS

Enter “X” for Answer

Number Question Yes No

Does your firm possess a valid and current California Contractor’s or other professional license as required by law for the project or projects for which it intends to submit a bid?

Is your firm registered with DIR as a Public Works Contractor for the current fiscal year?

Does your firm have a liability insurance policy with a policy limit of at least $1,000,000 per occurrence and $2,000,000 aggregate?

Does your firm have current workers’ compensation insurance policy as required by the Labor Code or is your firm legally self- insured pursuant to

Labor Code section 3700 et. seq.?

Have you attached your firm’s latest copy of reviewed or audited financial statements with accompanying notes and supplemental information? *

*NOTE: Financial statements that are not either reviewed or audited are not acceptable. A letter verifying availability of a line of credit may also be attached; however, it will be considered as supplemental information only, and is not a substitute for the required financial statements.

Have you attached a notarized statement from an admitted surety insurer

(approved by the California Department of Insurance) authorized to issue bonds in the State of California, which states that: (a) your current bonding capacity is sufficient for the project for which you seek pre-qualification if you are seeking pre- qualification for a single project; or valid for a year if you are seeking pre-qualification valid for a year; and (b) your current available bonding capacity? **

**NOTE: Notarized statement must be from the surety company, not an agent or broker.

Has your contractor’s or other professional license been revoked at any time in the last five years?

Has a surety firm completed a contract on your behalf, or paid for completion because your firm was in default and/or terminated by the project owner within the last five years?

Is your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section A and/or Section B, ineligible to bid on or be awarded a public works contract, or perform as a subcontractor on a public works contract, pursuant to Labor Code section 1777.1, Labor

Code section 1777.7, or any other federal, state, county, municipal or other local law providing for the debarment of contractors from public works?

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Has your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section A and/or Section B been convicted of a crime involving the awarding of a contract of a government construction project, the bidding or performance of a government contract, antitrust statutes, racketeering statutes, safety and health regulations, environmental laws, laws banning workplace discrimination, laws governing wages, hours or labor standards, or laws involving fraud, theft, or any other act of dishonesty?

Is your firm currently the debtor in a bankruptcy case?

(If yes, attach a copy of the bankruptcy petition showing the case number and date on which the petition was filed.)

Has your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section A and/or Section B ever been terminated from a public works contract, including but not limited to termination based on any misconduct, such as failure to comply with contractual, statutory, or other legal obligations from any public construction project?

Does your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section A and/or Section B currently have any delinquent liability to an employee, the state, or any awarding body for any assessment of back wages or related damages, interest, fines or penalties pursuant to any final judgment, order, or determination by any court or any federal, state, or local administrative agency, including a confirmed arbitration award?

* Public Contract Code section 20101(e) exempts from this requirement a contractor who has qualified as a small business pursuant to Government Code section 14837(d)(1), if the bid is “no more than 25 percent of the qualifying amount provided in section 14837(d)(1).” As of January 1, 2001, the qualifying amount is $10 million, and 25 percent of that amount, therefore, is $2.5 million.

** An additional notarized statement from the surety may be requested by [Public Entity] at the time of submission of a bid, if this pre-qualification questionnaire is submitted more than 60 days prior to submission of the bid.

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D. PRE-QUALIFICATION CRITERIA QUESTIONS

Prior History Enter X for Answer

1. How many times has your firm, or any of its officers, supervisors, or managers, declared bankruptcy at any time during the last five years?

(This question refers only to a bankruptcy action that was not described in your answer to Question 11 in Section C. If yes, attach a copy of the bankruptcy petition showing the case number and the date on which the petition was filed, a copy of the

Bankruptcy Court’s discharge order or any other document that concluded the case if no discharge order was issued.)

0 1 2 3 4 5+

2. How many times has your firm, or any of its officers, supervisors, or managers, had an injunction, judgment, order, or lien entered against it for outstanding taxes assessed or fines, penalties and/or unpaid employee wages at any time in the last five years?

(Explain on a separate sheet. Provide details, including the name of the government agency, caption, date, case or docket number, and disposition. Be sure to note any judgments or liens that have not been fully satisfied.)

0 1 2 3 4 5+

3. How many times in the past five years, has your firm, or any of its officers, supervisors, or managers, been a party in any civil litigation or administrative proceeding alleging violation of any of the following:

contract antitrust statutes, racketeering statutes, safety and health regulations, environmental laws, laws banning workplace discrimination, laws governing wages, hours or labor standards, or laws involving fraud, theft, or any other act of dishonesty?

(Explain on a separate sheet. Provide details including the nature of the claims and defenses, caption, date, case or docket number, name of the court or agency before which the case is pending or which it was heard, and current status.)

0 1 2 3 4 5+

4. How many times in the past five years, has your firm, or any of its officers, supervisors, or managers, been a party in any civil litigation or administrative proceeding alleging a violation by a subcontractor hired by your firm of any of the following: contract antitrust statutes, racketeering statutes, safety and health regulations, environmental laws, laws banning workplace discrimination, laws governing wages, hours or labor standards, or laws involving fraud, theft, or any other act of dishonesty?

(Explain on a separate sheet. Provide details including the nature of the claims and defenses, caption, date, case or docket number, name of the court or agency before which the case is pending or which it was heard, and current status.)

0 1 2 3 4 5+

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5. How many times in the past five years, has your firm, or any of its officers, supervisors, or managers, paid any amount, fine or otherwise, regardless of characterization, to settle any of the allegations listed in

Questions 3 and 4 above, whether with or without an admission of responsibility or liability?

(Explain on a separate sheet. Provide details, including the caption, date, case or docket number, and name of the court or agency before which the case was brought.)

0 1 2 3 4 5+

6. How many times has your firm, or any of its officers, supervisors, or managers, been debarred, suspended, disqualified, denied a classification rating or pre-qualification or otherwise been declared not responsible to or prevented from bidding or performing work on any public works contract or subcontract in the last five years?

(Explain on a separate sheet. State whether the firm involved was the firm applying for pre-qualification here or another firm. Identify by name of the company, name of the person within your firm who was associated with that company, date, owner of the project, project name and information, basis for the action, and case or docket number.)

0 1 2 3 4 5+

7. How many times in the last five years has your firm been assessed and paid liquidated damages after completion of a project under a construction contract with either a public or private owner?

(Explain on a separate sheet. Identify all such projects by owner, owner’s address, date of completion of the project, amount of liquidated damages assessed and all other information necessary to fully explain the assessment of liquidated damages.)

0 1 2 3 4 5+

8. How many times during the past five years, has any surety company made any payments on your firm’s behalf as a result of a default, to satisfy any claims made against a performance or payment bond issued on your firm’s behalf, in connection with a construction project, either public or private?

(Explain on a separate sheet. Identify the amount of each such claim, name and telephone number of the claimant, date of claim, grounds for claim, present status of claim, date of resolution of such claim if resolved, method by which claim was resolved if resolved, nature of resolution and amount, if any, at which claim was resolved.)

0 1 2 3 4 5+

9. How many times in the last five years has any insurance carrier, for any form of insurance, refused to renew an insurance policy for your firm?

(Explain on a separate sheet. Name the insurance carrier, form of insurance, and year of refusal.)

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10. How many times during the last five years, has your firm been denied bond coverage by a surety company, or has there been a period of time when your firm had no surety bond in place during a public works construction project when one was required? coverage, name of the company or companies which denied coverage, and the time period during which you had no surety bond in place.)

(Explain on a separate sheet. Indicate the date when your firm was denied

Criminal Matters and Civil Suits Enter X for Answer

11. How many times has your firm, or any of its officers, supervisors, or managers, ever been convicted of a crime involving any federal, state, or local law related to construction?

Explain on a separate sheet. Identify who was involved, name of the public agency, date of conviction, and grounds for conviction.)

0 1 2 3 4 5+

12. How many times has your firm, or any of its officers, supervisors, or managers, ever been found liable in a civil suit or convicted of a federal or state crime of fraud, theft, or involving any other act of such as making any false claim or material misrepresentations?

(Explain on a separate sheet. Identify the person or persons convicted or found liable, court [the county if a state court, the district or location if federal court], year, and conduct involved.)

0 1 2 3 4 5+

13. How many times has your firm, or any of its officers, supervisors, or managers, ever been found liable in a civil suit or convicted of a federal or state crime of fraud, theft, or involving any other act of dishonesty, such as making any false claim or material misrepresentations?

(Explain on a separate sheet. Identify the person or persons convicted or found liable, court [the county if a state court, the district or location if federal court], year, and conduct involved.)

0 1 2 3 4 5+

NOTE: The following two questions refer only to disputes between your firm and the owner of a project. You need not include information about disputes between your firm and a supplier, another contractor, or subcontractor. You need not include information about “pass-through” disputes in which the actual dispute is between a sub-contractor and a project owner. Also, you may omit reference to all disputes involving amounts of less than $50,000.

14. How many times in the last five years has any claim against your firm concerning your firm’s work on a construction project been filed in court or arbitration?

(Explain on a separate sheet. Identify the claim(s) by providing the project name, date of the claim, name of the claimant, a brief description of the nature of the claim, the court in which the case was filed and a brief description of the status of the claim

[e.g. "pending" or, if resolved, a brief description of the resolution].)

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15. How many times in the last five years has your firm made any claim against a project owner concerning work on a project or payment for a contract and filed that claim in court or arbitration?

(Explain on a separate sheet. Identify the claim(s) by providing the project name, date of the claim, name of the entity (or entities) against whom the claim was filed, a brief description of the nature of the claim, the court in which the case was filed and a brief description of the status of the claim [e.g. "pending" or if resolved, a brief description of the resolution].)

Occupational Health and Safety Compliance Enter X for Answer

16. How many times in the last five years has CalOSHA cited and assessed penalties against your firm for any “serious,” “willful” or “repeat” violation(s) or the federal Occupational Safety and Health Administration cited and assessed penalties against your firm for violation(s) of safety or health regulations?

NOTE: If you have filed an appeal of a citation, and the Occupational Safety and

Health Appeals Board has not yet ruled on your appeal, you need not include information about it.

0 1 2 3 4 5+

17. How many times in the last five years has the EPA or any Air Quality

Management District or any Regional Water Quality Control Board cited and assessed penalties against either your firm or the owner of a project on which your firm was the contractor?

(Explain on a separate sheet describing each citation.)

NOTE: If you have filed an appeal of a citation and the Appeals Board has not yet ruled on your appeal, or if there is a court appeal pending, you need not include information about the citation.

Prevailing Wage and Apprenticeship Compliance Enter X for Answer

18. How many times during the last five years, has your firm been required to pay back wages and/or penalties related to state or federal prevailing wage laws for work performed by your firm?

(Explain on a separate sheet. Describe the nature of each violation and identify the name of the project, date of its completion, public agency for which it was constructed, number of employees underpaid, and amount(s) of back wages and penalties your firm was required to pay.)

NOTE: Question 18 refers only to the violation of prevailing wage laws by your firm, not to violations by a subcontractor.

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19. How many times during the last five years, has your firm or any subcontractors hired by your firm been required to pay back wages and/or penalties related to state or federal prevailing wage laws for work performed by a subcontractor?

(Explain on a separate sheet. Identify the subcontractor’s business name and CSLB license number, describe the nature of each violation, and identify the name of the project, date of its completion, public agency for which it was constructed, number of employees underpaid, and amount(s) of back wages and penalties your firm was required to pay.)

NOTE: This question refers only to the violation of prevailing wage laws by subcontractors, not to violations by your firm.

0 1 2 3 4 5+

20. How many times during the last five years, has your firm paid any penalties related to any provision of California apprenticeship laws or regulations, or the laws pertaining to use of apprentices on public works projects, including Labor Code sections 1777.5 and 1777.7?

(Explain on a separate sheet. Provide the date(s) of such findings, case number(s), and attach copies of the Department’s final decision(s).)

21. How many times during the last five years, has any subcontractor hired by your firm paid any penalties related to any provision of California apprenticeship laws or regulations, or the laws pertaining to use of apprentices on public works projects, including Labor Code sections

1777.5 and 1777.7?

(Explain on a separate sheet. Provide the date(s) of such findings, case number(s), and attach copies of the Department’s final decision(s).)

NOTE: Omissions, misrepresentations and any failure to disclose associations with other firms or any prior history of alleged violations may lead to loss of your eligibility to register as a Public Works Contractor, disqualification of bids, and/or grounds for termination of a contract.

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E. PROJECT REFERENCES

Provide information…