Bidder's_Questionnaire.pdf

BIDDER’S QUESTIONNAIRE

Fire Station No. 3 Driveway Repair Project

Within 48 hours following a request by City, a bidder must submit to City a completed, signed Bidder’s Questionnaire using this form and all required attachments, including clearly labeled additional sheets as needed. City may request the Questionnaire from one or more of the apparent low bidders following the bid opening, and may use the completed Questionnaire as part of its investigation to evaluate a bidder’s qualifications for this Project. The Questionnaire must be filled out completely, accurately, and legibly.

Any errors, omissions, or misrepresentations in completion of the Questionnaire may be grounds for rejection of the bid or termination of a Contract awarded pursuant to the bid.

Part A: General Information

Bidder Business Name: _______________________________________________ (“Bidder”)

___ Corporation (State of incorporationCheck One: : ___________________) ___ Partnership ___ Sole Proprietorship

___ Joint Venture of: ___________________________________ ___ Other: ___________________________________________

Main Office Address and Phone: ______________________________________

Local Office Address and Phone: _____________________________________

Website address: __________________________________________________

Owner of Business: _________________________________________________

Contact Name and Title: _____________________________________________

Contact Phone and Email: ___________________________________________

Bidder’s California Contractor’s License Number(s): _______________________

Bidder’s DIR Registration Number: ____________________________________

Part B: Bidder Experience

1. How many years has Bidder been in business under its present business name? ____ years

2. Has Bidder completed projects similar in type and size to this Project as a general contractor?

_____ Yes _____ No

3. Has Bidder ever been disqualified from a bid on grounds that it is not responsible, or otherwise disqualified or debarred from bidding under state or federal law?

_____ Yes _____ No

If yes, provide additional information on a separate sheet regarding the disqualification or debarment, including the name and address of the agency or owner of the project, the type and size of the project, City of Napa Public Works Contract Documents Form 4.1 (2023-12-22) Fire Station No. 3 Driveway Repair Project BIDDER’S QUESTIONNAIRE City Project No. FC25FD01 Page 1 the reasons that Bidder was disqualified or debarred, and the month and year in which the disqualification or debarment occurred.

4. Has Bidder ever been terminated for cause, alleged default, or legal violation from a construction project, either as a general contractor or as a subcontractor?

_____ Yes _____ No

If yes, provide additional information on a separate sheet regarding the termination, including the name and address of the agency or owner of the subject project, the type and size of the project, whether Bidder was under contract as a general contractor or a subcontractor, the reasons that Bidder was terminated, and the month and year in which the termination occurred.

5. Provide information about Bidder’s past projects performed as general contractor as follows:

5.1 Six most recently completed public works projects within the last three years;

5.2 Three largest completed projects within the last three years; and

5.3 Any project which is similar to this Project including scope and character of the work.

6. Use separate sheets to provide all of the following information for each project identified in response to the above three categories:

Project name, location, and description;6.1 Owner (name, address, email, and phone number);6.2 Prime contractor, if applicable (name, address,6.3 email, and phone number);

Architect or engineer (name, email, and phone n6.4 umber);

Project and/or construction manager (name, emai6.5 l, and phone number);

Scope of work performed (as general contractor6.6 or as subcontractor);

Initial contract price and final contract price6.7 (including change orders);

Original scheduled completion date and actual d6.8 ate of completion;

Time extensions granted (number of days);6.9 Number and amount of stop notices or mechanic’6.10 s liens filed;

Amount of any liquidated damages assessed agai6.11 nst Bidder; and Nature and resolution of any project-related c6.12 laim, lawsuit, mediation, or arbitration involving Bidder.

Part C: Safety

1. Provide Bidder’s Experience Modification Rate (EMR) for the last three years:

EMRYear

2. Complete the following, based on information provided in Bidder’s CalOSHA Form 300 or Form 300A, Annual Summary of Work-Related Illnesses and Injuries, from the most recent past calendar year:

____Number of lost workday cases:2.1 ____Number of medical treatment cases:2.2 ____Number of deaths:2.3

City of Napa Public Works Contract Documents Form 4.1 (2023-12-22) Fire Station No. 3 Driveway Repair Project BIDDER’S QUESTIONNAIRE City Project No. FC25FD01 Page 2

3. Has Bidder ever been cited, fined, or prosecuted by any local, state, or federal agency, including OSHA, CalOSHA, or EPA, for violation of any law, regulation, or requirements pertaining to health and safety?

_____ Yes _____ No

If yes, provide additional information on a separate sheet regarding each such citation, fine, or prosecution, including the name and address of the agency or owner of the project, the type and size of the project, the reasons for and nature of the citation, fine, or prosecution, and the month and year in which the incident giving rise to the citation, fine, or prosecution occurred.

4. Name, title, and email for person responsible for Bidder’s safety program:

EmailTitleName

Part D: Verification

In signing this document, I, the undersigned, declare that I am duly authorized to sign and submit this Bidder’s Questionnaire on behalf of the named Bidder, and that all responses and information set forth in this Bidder’s Questionnaire and accompanying attachments are, to the best of my knowledge, true, accurate and complete as of the date of submission. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Signature: ______________________________ Date: ________________

By: _______________________________________________________________ Name and Title

END OF BIDDER’S QUESTIONNAIRE

City of Napa Public Works Contract Documents Form 4.1 (2023-12-22) Fire Station No. 3 Driveway Repair Project BIDDER’S QUESTIONNAIRE City Project No. FC25FD01 Page 3