19-Pre-Qualification Questionnaire Blank.pdf

Azusa Unified School District Pre-qualification Questionnaire 2024

AZUSA UNIFIED SCHOOL DISTRICT

PRE-QUALIFICATION

QUESTIONNAIRE

Pre-qualification Questionnaire 2024

Contents

SECTION 1: CONTRACTOR INFORMATION

SECTION 2: CURRENT ORGANIZATION AND STRUCTURE

SECTION 3: ESSENTIAL CRITERIA QUESTIONS

SECTION 4: PRE-QUALIFICATION CRITERIA QUESTIONS

SECTION 5: PROJECT REFERENCES

SECTION 6: CERTIFICATION

Pre-qualification Questionnaire 2024

CONTRACTOR PRE-QUALIFICATION QUESTIONNAIRE

SECTION 1: 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

Pre-qualification Questionnaire 2024

SECTION 2: CURRENT ORGANIZATION AND STRUCTURE

Complete the Section 2elow 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 with Firm

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:

Name Position Years with Firm

Ownership

Pre-qualification Questionnaire 2024

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 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.

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 with

Firm

Pre-qualification Questionnaire 2024

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.

Person’s Name Construction Firm Date of Person’s 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

Pre-qualification Questionnaire 2024

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

Pre-qualification Questionnaire 2024

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.

Pre-qualification Questionnaire 2024

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 1 or

Yes ☐NoSection 2 above at any time in the past five years?

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

Name Construction Firm Dates of Participation

Pre-qualification Questionnaire 2024

SECTION 3: ESSENTIAL CRITERIA QUESTIONS

1. 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?

2. Is your firm registered with DIR as a Public Works Contractor for

Check Answer

☐ Yes ☐ No

☐ Yes ☐ No the current fiscal year?

3. 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?

4. 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.?

5. 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.

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

6. 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? **

☐ Yes ☐ No

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

7. Has your contractor’s or other professional license been revoked at any time in the last five years? ☐ Yes ☐ No

8. 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?

☐ Yes ☐ No

Pre-qualification Questionnaire 2024

9. Is your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section 1 and/or Section 2, 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?

Check Answer

☐ Yes ☐ No

10. Has your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section 1 and/or Section 2 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?

☐ Yes ☐ No

11. 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.)

12. Has your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section 1 and/or Section 2 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?

☐ Yes ☐ No

☐ Yes ☐ No

13. Does your firm, any of its officers, supervisors, managers, or any firm or individual identified above in Section 1 and/or Section 2 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?

☐ Yes ☐ No

* 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 Azusa Unified School District 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.

Pre-qualification Questionnaire 2024

SECTION 4: PRE-QUALIFICATION CRITERIA QUESTIONS

Prior History Check Answer

0 1 2 3 4 5+

0 1 2 3 4 5+

0 1 2 3 4 5+

0 1 2 3 4 5+

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 3. 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.)

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.)

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.)

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.)

Pre-qualification Questionnaire 2024

Check Answer

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, 0 1 2 3 4 5+ 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.)

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.)

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?

0 1 2 3 4 5+

(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.)

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 0 1 2 3 4 5+ 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.)

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? 0 1 2 3 4 5+

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

0 1 2 3 4 5+

Pre-qualification Questionnaire 2024

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?

(Explain on a separate sheet. Indicate the date when your firm was denied coverage, name of the company or companies which denied coverage, and the time period during which you had no surety bond in place.)

0 1 2 3 4 5+

Criminal Matters and Civil Suits

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 0 1 2 3 4 5+ 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.)

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 dishonesty, 0 1 2 3 4 5+ 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.)

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.

13. 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?

0 1 2 3 4 5+

(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].)

14. 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?

0 1 2 3 4 5+

(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].)

Pre-qualification Questionnaire 2024

Occupational Health and Safety Compliance Check Answer

15. How many times in the last five years has CalOSHA cited and assessed penalties against your firm for any “serious,” “willful” or “repeat”

0 1 2 3 4 5+ 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.

16. 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

0 1 2 3 4 5+ 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.

17. How many times within the last five years has there ever been a period when your firm had employees but was without workers’ compensation insurance or state-approved self-insurance?

0 1 2 3 4 5+

(Explain the reason for each absence of workers’ compensation insurance on a separate sheet. If “None,” please provide a statement by your current workers’ compensation insurance carrier that verifies periods of workers’ compensation insurance coverage for the last five years. If your firm has been in the construction business for less than five years, provide a statement by your workers’ compensation insurance carrier verifying continuous workers’ compensation insurance coverage for the period that your firm has been in the construction business.)

Prevailing Wage and Apprenticeship Compliance

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.

0 1 2 3 4 5+

Pre-qualification Questionnaire 2024

Check Answer

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 0 1 2 3 4 5+ 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.

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

0 1 2 3 4 5+ 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

0 1 2 3 4 5+ 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.

Pre-qualification Questionnaire 2024

SECTION 5: PROJECT REFERENCES

Provide information about the firm’s six most recently completed public works projects and its three largest completed private projects within the last three years. Names and references must be current and verifiable. Use separate sheets of paper that contain all of the following information*:

For General Contractors: Only list projects your firm performed as the general contractor.

For Subcontractors: Only list projects your firm performed as the prime contractor if a single trade job or as a subcontractor on a multiple trade contract. For multiple trade contracts, indicate the general contractor’s name and contact information.

Project Name:

Location:

Owner:

Owner Contact (name and current phone number):

Architect or Engineering Firm:

Architect or Engineer Contact (name and current phone number):

Construction Manager (name and current phone number):

Inspector of Record (name and current phone number):

Description of Project, Scope of Work Performed:

Total Value of Construction (including change orders):

Date Construction Commenced:

Original Contractual Completion Deadline:

Adjusted Completion Deadline Based on Time Extensions Granted by Owner:

Actual Date of Completion:

General Contractor’s Project Manager (lead contact in office), if applicable:

General Contractor’s Superintendent (lead contact on project site), if applicable:

* You may also provide information about other projects that you have completed that are similar to the project(s) for which you expect to bid using the same format.

Pre-qualification Questionnaire 2024

SECTION 6: CERTIFICATION

Questionnaires submitted by corporations must be signed with the legal name of the corporation, followed by the name of the state of incorporation and by the signature and designation of the chairman of the board, president or any vice president, and then followed by a second signature by the secretary, assistant secretary, the chief financial officer or assistant treasurer. All persons signing must be authorized to bind the corporation in the matter. The name of each person signing shall also be typed or printed below the signature.

Satisfactory evidence of the authority of each officer signing on behalf of a corporation shall be furnished.

Questionnaires submitted by partnerships must furnish the full name of all partners and must be signed in the partnership name by a general partner with authority to bind the partnership in such matters, followed by the signature and designation of the person signing. The name of the person signing shall also be typed or printed below the signature.

Each person signing below makes the following representations under penalty of perjury:

The submitter of the foregoing answers to the questionnaire has read the same and the matters stated therein are true to the best of his or her own personal knowledge. This information is provided for the purpose of qualifying to bid on the Project, and any individual, company or other agency named herein is hereby authorized to supply the awarding body with any information necessary to verify the prospective bidder’s statements. By signing below, the submitter and the named contractor hereby grant permission to the [Public Entity] to contact any or all of the above listed persons or entities to confirm facts or otherwise investigate the above facts and issues.

The submitter understands that any statement which is proven to be false shall be grounds for immediate disqualification from bidding on the Project. The submitter whose signature appears below represents and warrants that he or she has authority to bind the named contractor.

I, (Name), the undersigned, am the (Title), with the authority to act for and on behalf of (Contractor Entity Name), declare under penalty of perjury under the laws of the State of California that the foregoing information provided in this Pre-qualification Questionnaire is true, full, and correct.

I understand that making a false statement may result in disqualification from bidding on any public works project, registering as a Public Works Contractor with the Department of Industrial Relations, and may be grounds for termination of a public works contract.

Executed on this: day of at ___________________ (Date) (Month / Year) (City / State)

Name of Contractor Representative:

Signature of Contractor Representative:

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