DB_Qualificiation_Statement_FINAL.docx

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Attached to
Design-Build Services for a Hydrogen Fueling Station
Solicitation number
2026-RFP-0123
Issued by
Los Angeles County, California

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Written by GovTribe AI ·

This Design-Builder Qualification Statement is a form required by the City of Pasadena for contractors seeking to bid on design-build services for a hydrogen fueling station project. The qualification statement establishes essential requirements that proposers must meet, including the ability to obtain required insurance with specified scope and limits, current workers' compensation insurance coverage, bonding capacity exceeding the City's estimated direct cost of work, an Experience Modification Rate (EMR) of 1.25 or less for the most recent three-year period, a minimum of five years in business under the applicable contractor's license, and demonstrated completion of at least three prevailing wage public contracts in California and three similar projects with comparable scope and scale valued at more than $8 million each within seven years prior to proposal submission. The form disqualifies any proposer whose California contractor's license has been revoked within five years, whose surety has completed a contract on their behalf due to default termination, who is currently ineligible to bid on public works contracts, who has been convicted of crimes involving government contracts, or who has unsatisfactory prior performance with the City or has filed claims or lawsuits against the City within the past five years.

The qualification statement requires extensive documentation and disclosure, including current contact information, bonding company history, insurance coverage details, Experience Rating Forms, bank references, three years of reviewed or audited financial statements, organizational structure details, designated project manager and superintendent information with relevant project experience, and disclosure of any claims exceeding $25,000, litigation, arbitration, or project terminations. Proposers must declare under penalty of perjury that all information provided is truthful and complete. This comprehensive qualification process is designed to ensure that only contractors with demonstrated financial strength, safety records, relevant experience, and clean regulatory and legal histories are considered for the hydrogen fueling station design-build project.

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DESIGN-BUILDER QUALIFICATION STATEMENT

GENERAL

To be considered, all information requested must be submitted on this Design-Builder Qualification Statement form or, to the extent this form does not provide sufficient space to fully respond, Proposers should attach additional sheets as necessary referencing the appropriate paragraph number and subparagraph.

All questions must be answered, and the data must be clear and complete. Line items that do not require a response shall be noted with a “N/A” referencing items that are not applicable.

PART I ESSENTIAL REQUIREMENTS FOR QUALIFICATION

Contractor’s Proposal will be rejected if the answer to any of questions 1 through 6 is “no,” or if the answer to any of questions 7, through 12 is “yes.”

1.Design-Builder can obtain insurance for the RFP submittal with the minimum scope and limits specified in “The Scope of Work” of the Agreement.
|_|Yes|_|No
2.Design-Builder has current workers’ compensation insurance policy as required by the Labor Code or is legally self-insured pursuant to Labor Code section 3700 et seq.
|_|Yes|_|No
|_|Design-Builder is exempt from this requirement, because it has no employees
3.Are you prepared to submit a notarized statement from a California Admitted Surety Insurer (approved by the California Department of Insurance) and authorized to issue bonds in the State of California with your Price Proposal, which states that your total bonding capacity and your total available bonding capacity is in excess of City’s estimate of the Direct Cost of the Work, which must be confirmed with your Price prior to contract City authorization to proceed?
|_|Yes|_|No

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

4.Are you prepared to submit documentation from your insurance carriers (Experience Rating Forms, not summaries) establishing that your Experience Modification Rate (“EMR”) for the most recent three-year period is an average of 1.25 or less.
|_|Yes|_|No
5.Have you (or if Proposer is a joint venture, each of your joint venture members) been in business for a minimum of five (5) years under the contractor’s license used for the Proposal you are submitting?
|_|Yes|_|No
6.Have you satisfactorily completed: 1) at least three (3) prevailing wage public contract in California; and 2) at least three (3) similar projects comparable in scope and scale to this Project, successfully completed within seven (7) years prior to the Proposal Submission Deadline and with the dollar value of Proposer’s portion of each such project more than $8M? (See Part II of this Design-Builder Qualification Statement, item 22.)
|_|Yes|_|No
7.Has your California contractor’s license been revoked at any time in the last five (5) years?
|_|Yes|_|No
8.Has a surety firm completed a contract on your behalf, or paid for completion because your firm was default terminated by the project owner within the last five (5) years?
|_|Yes|_|No
9.At the time of submitting this form, is your firm ineligible to bid on or be awarded a public works contract, or perform as a subcontractor on a public works contract, pursuant to either Labor Code section 1725.5, 1777.1 or Labor Code section 1777.7?
|_|Yes|_|No
If the answer is “Yes,” state the beginning and ending dates of the period of debarment:
10.At any time during the last five years, has your firm, or any of its owners or officers, been convicted of a crime involving the awarding of a contract of a government construction project, or the bidding or performance of a government contract?
|_| Yes|_| No
11.Has your prior performance on a project for the City within the last five (5) years has been unsatisfactory?
|_| Yes|_| No
12.Have you filed a Government Code claim or lawsuit against the City within the last five (5) years?
|_| Yes|_| No

3323790.2 3323790.2

March 2026

DESIGN-BUILDER QUALIFICATION STATEMENT

PASADENA HYDROGEN FUELING STATION PROJECT

DESIGN-BUILDER QUALIFICATION STATEMENT

PART IIQUESTIONNAIRE
1.Name of Firm:
(a)Type of Entity: ( ) Corporation( ) Partnership( ) Individual( ) Joint venture( ) Limited Liability Company ( ) Other

(b) Address:

City:State:Zip:
(c)Telephone No: ( )

Facsimile No: ( )

(d)E-mail address:
(e)California Contractors License Number:

(Attach documentation from the Contractors State Licensing Board (e.g. printed from website) establishing this license number is valid.)

(f)Identify years in business for the contractor’s license identified in (e).
2.Complete the following information for all bonding companies utilized by your organization in the last five (5) years. (Attach separate sheets for each bonding company.)
(a)Name of Bonding Company:
(b)Address:
(c)City:State:Zip:
(d)Contact Name/Title:
(e)Telephone No: ( )
(f)Facsimile No: ( )

(g) E-mail address:

(h) Type of bonds issued (license, performance, payment, etc.):

(i) Period of bonding (insert dates):

3.Complete the following information for each project for which a bonding company has had to complete any part of your work during the last five (5) years. (Attach additional sheets as necessary.)
(a)Project:
(b)Amount Bonded:
(c)Bonding Company:
(d)Percent of Project Completed:
(e)Name of Contractor Completing Project:
4.Provide the following information for each type of insurance coverage required for the Project (attach additional sheets as necessary):
(a)Name of Insurance Company:
(b)Address:
(c)City:State:Zip:
(d)Contact Name/Title:
(e)Telephone No: ( )
(f)Facsimile No: ( )
5.Attach copies of your Experience Rating Forms (not summaries) from your insurance carrier(s) establishing that your Experience Modification Rate (“EMR”) for the most recent three-year period is an average of 1.25 or less.
6.Complete the following Bank Reference information: (List at least two references, attach additional sheets)
(a)Name of Institution:
(b)Address:
(c)City:State:Zip:
(d)Contact Name/Title:
(e)Telephone No: ( )
(f)Email:
7.Complete the following information regarding your business volume:
(a)Average annual billable volume (past 5 years): $
(b)Estimated billable volume this year: $
(c)Estimated volume to carry over next year. $
8.Attach a reviewed or audited financial statement for the past three (3) years, including the contractor's latest balance sheet and income statement showing the following items:
(a)Current assets (e.g., cash, joint venture accounts, accounts receivable, notes receivable, accrued income, deposits, materials inventory and prepaid expenses).
(b)Net fixed assets.
(c)Other assets.
(d)Current assets (e.g., accounts payable, notes payable, accrued expenses, revisions for income taxes, advances, accrued salaries and accrued payroll taxes).
(e)Other liabilities (e.g., capital, capital stock, authorized and outstanding share par values, earned surplus and related earnings).
(f)Names of firm preparing financial statement and date thereof.
(g)Is this financial statement for the identical organization named on Page 1 of this Contractor’s Qualification statement?

If not, explain the relationship and financial responsibility of the organization whose financial statement is provided (e.g., parent-subsidiary).

(h)Will this organization act as guarantor of the contractor for construction?
9.How many years has your organization been in business?
10.What year was your organization established?
11.Identify total number of permanent employees:
(a)Construction
(b)Administration
(c)Engineering
(d)Type of Engineering Performed:
(e)Highest Manpower Level in Past Five Years:
(f)Lowest Manpower Level in Past Five Years:
12.How many years has your organization been in business under its present business name?

13. Under what other or former names has your organization operated?

14.Identify parent company if applicable:
15.List affiliates, divisions and subsidiaries if applicable:
(a)Name:

Address:

City: State: Zip:

Telephone No: ( ) Facsimile No: ( )

16.If a corporation, complete the following:
(a)Date of Incorporation:
(b)Name of Sate(s) in which incorporated:
(c)President's Name:
(d)Vice President's Name:
(e)Secretary's Name:
(f)Treasurer's Name:
17.If a partnership, complete the following:
(a)Date of Organization:
(b)Is the Partnership:( ) General( ) Limited( ) Association
18.List names and addresses of all partners:

(a) Name:

Address:

City: State: Zip:

Telephone No: ( ) Facsimile No: ( )

19.If other than a Corporation or Partnership, describe type of organization and name of principals:
OwnerPercentage of Ownership
20.Have you ever been licensed under a different name or different license number?
|_|Yes|_|No

If the answer is yes, give name and license number.

21.NOT USED
22.Provide the name of the designated Project Manager and Project Superintendent and provide the following information for each project which qualifies that individual for this position.

(a) Name of Project Manager/Superintendent:

(b) Name of Project:

(c) Client:

(d) Project Address:

City:State:Zip:
(d)Contact Name:
(e)Contact Phone and email: ( )
(f)Architect Name:
(g)Architect Phone: ( )
(h)Type of Facility:
(i)Contract Type:
(j)Contract Amount:
(k)Percent Change Orders to Base Contract:
(l)Percent Complete:
(m)Percent Work Performed With Own Forces:
(n)Scheduled Completion Date:
(o)Actual Completion Date:

(p) Explain any differences between scheduled and actual completion dates:

(q) Explain any differences between the original contract price and the actual cost to complete:

23.NOT USED
24.List any projects in which your organization has been involved in any claim for defective work, delay, extra work, or equitable contract adjustment in the last five years in which the amount in controversy exceeded $25,000. Identify claims by project name, parties involved, description of claim and ultimate resolution (attach additional sheets as necessary):
(a)Project Name:

(b) Project Location:

(c) Date of Claim:

(a) Parties Involved:

(b) Description of Claim:

(c) Result:

25.Complete the following information for each project in which your organization has been involved in litigation or arbitration with a public agency. Identify lawsuits by name, court, case number and parties. Briefly describe the nature of the claim, the amount of any judgment or settlement and in whose favor. (Attach additional sheets as necessary.)
(a)Project Name:
(b)Project Location:
(c)Lawsuit Name:
(d)Court/Case Number:
(e)Date of Lawsuit:
(f)Parties Involved:
(g)Description of Claim:
(h)Result:
26.List any projects in which your organization has been involved in any claim for defective work, delay, extra work or equitable contract adjustment with the Owner or another entity. Identify claims by project name, parties involved, description of claim and ultimate resolution (attach additional sheets as necessary):
(a)Project Name:
(b)Project Location:
(c)Date of Claim:
(d)Parties Involved:
(e)Description of Claim:
(f)Results:
27.Has your organization ever been terminated from a project, either for convenience and or default, before completion? If so, provide the following information: (List five projects maximum, attach additional sheets as necessary.)
(a)Project Name:
(b)Project Location:
(c)Client Name:
(d)Client Contact:
(e)Client Telephone No:
(f)Architect Name:
(g)Architect Telephone No:
(h)Date of Termination:
(i)Reason for Termination:
28.Has the Proposer, any officer of the Proposer, or any employee of the Proposer who has a proprietary interest in the Proposer, ever been disqualified, removed, or otherwise prevented from bidding on, competing for, or completing a federal, state or local government project because of a violation of law or a safety regulation?
|_|Yes|_|No

If the answer is yes, explain the circumstances in the following space. Attach additional sheets if necessary.

I, the undersigned, certify and declare that I have read all the foregoing answers to the questionnaire and know their contents. The matters stated in the questionnaire answers are true of my own knowledge and belief, except as to those matters stated on information and belief, and as to those matters, I believe them to be true. I declare under penalty of perjury under the laws of the State of California, that the foregoing is correct.

Executed in:

(County), (State) on (Date)

(Signature)

(Title)

END OF DOCUMENT

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