26-014R WRWWTF Electrical Building Design-Build D-B Entity Qualifications Questionnaire.docx

DESIGN-BUILD ENTITY QUALIFICATIONS QUESTIONNAIRE

WESTERN REGION WASTEWATER TREATMENT FACILITY PHASE 2 ELECTRICAL BUILDING & RESILIENCY IMPROVEMENTS PROGRESSIVE DESIGN-BUILD

PBCWUD PROJECT NO. 26-014R, PACKAGE IDENTIFICATION NO. GL04

PALM BEACH COUNTY, FLORIDA

As required by the County, this form should be completed and returned to the County with the proposal. Each Proposer should provide evidence that, as of the date of Proposal Document submission, the Design-Build Entity, were qualified to do business in the State of Florida and Palm Beach County.

1. Prime/Lead Contractor's Legal Name and Address:

Name: _______________________________________________________________________

Address: _____________________________________________________________________

City:___________________________ State _________ Zip Code:_______________

Check One: Corporation: ______ Partnership: ______ LLC _______

Individual: ______ Joint Venture: ______

If a Corporation or LLC, state:

Date of Incorporation or Organization :_______________________________

State in which Incorporated or Organized:__________________________

If an out‑of‑state corporation or LLC which is currently authorized to do business in the State of Florida, give the date of such authorization: __________________________

Names and Titles of Principal Officers or Managing Members (LLC)

Date Elected:

If a Partnership, state:

Date of Partnership: _______________________

Type of Partnership (General or Limited): __________________

Names and Addresses of Partners: ____________________________________

If Joint Venture, state:

Date of Joint Ventureship: __________________

Names and Addresses of Joint Venturers:

If Sole Proprietorship, state:

Name and Address of Sole Proprietor:

List corporate names or business names under which each of the principals in the present corporation have done business for the last ten (10) years:

List all subsidiaries or holding companies:

2. Contractor's License: _________________ Primary Classification ____________

State License No.:

Supplemental classifications held, if any:

Name of Licensee, if different from (1) above:

3. What is the maximum bonding capacity of your company?

(A) Capacity (Dollar Amount):

(B) Include the company name, phone number, address and name of the Florida Resident Agent of your current bonding company:

4. Has your organization or any member been involved in any litigation or arbitration within the last five (5) years as a result of construction contracts, including but not limited to liens, defective performance or workmanship? If yes, provide the following information for each case (attach additional sheets as necessary):

(A) Style or caption of litigation or arbitration: ________________________________

(B) All parties to such proceedings:

(C) Names, Addresses, and Telephone Numbers of Attorneys for each party:

(D) Date Litigation Started:

(E) Status of Case:

5. Have you or any principal of your company ever declared bankruptcy?

Yes ______ No ______

If yes, provide dates and particulars:

Date Reason

6. Have you ever failed to complete work awarded to you? If so, where and why?

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