NONCOLLUSION;_AAs_SUB;_QUAL;_PUBCONTR_CODE;_DEBARMENT;_ELIGIBILITY;_AND_IDENTITY_CONF;_SUBSTITUT_VALUE.pdf

DECLARATION OF NONCOLLUSION BY CONTRACTOR

TO BE EXECUTED

BY BIDDER AND SUBMITTED WITH BID

The undersigned declares:

I am the of , the party making the foregoing Bid.

The Bid is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation. The Bid is genuine and not collusive or sham.

The Bidder has not directly or indirectly induced or solicited any other Bidder to put in a false or sham Bid. The Bidder has not directly or indirectly colluded, conspired, connived, or agreed with any Bidder or anyone else to put in a sham Bid, or to refrain from bidding. The Bidder has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the Bid price of the Bidder or any other Bidder, or to fix any overhead, profit, or cost element of the Bid price, or of that of any other Bidder. All statements contained in the Bid are true. The Bidder has not, directly or indirectly, submitted his or her Bid price or any breakdown thereof, or the contents thereof, or divulged information or data relative thereto, to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof, to effectuate a collusive or sham Bid, and has not paid, and will not pay, any person or entity for such purpose.

Any person executing this declaration on behalf of a Bidder that is a corporation, partnership, joint venture, limited liability company, limited liability partnership, or any other entity, hereby represents that he or she has full power to execute, and does execute, this declaration on behalf of the Bidder.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that this declaration is executed on

(date), at (city), (state).

By: Title:

Purchasing Division 100 N. Garfield, Room S348 Pasadena, CA 91101 Phone (626) 744-6755 https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Vendor Questionnaire (Form AA-1)

Affidavit of Equal Opportunity Employment & Non-segregation By submitting this form you are declaring under penalty of perjury under the laws of the State of California and the laws of the

United States that the information is true and correct. Furthermore, you are certifying that your firm will adhere to equal opportunity employment practices to assure that applicants and employees are not discriminated against because of their race, religion, color, national origin, ancestry, disability, sex or age. And, your firm does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform their services at any location, under its control, where segregated facilities are maintained. Additionally, no employees, consultants, or board members of your company or your subcontractors are current employees of the City of

Pasadena.

Name of Company:

Address:

State:

Contact Person:

Telephone:

E-mail Address:

City:

Zip:

DBA (if applicable):

Remit Address (if different):

Please state clearly and concisely the type(s) of goods and services your company would provide on this contract

Active City of Pasadena Business License Number:

Required For All Public Works: Pursuant to Division 2, Part 7, Chapter 1 (commencing with section 1720) of the California Labor Code, you must provide your Registration Number under the Department of Industrial Relations:

Small and Micro Business Preference Program: If certified by California Department of General Services as a small or micro business, please provide DGS Reference Number:

(Visit the Purchasing Division website for additional information):

The following section is OPTIONAL and is for statistical reporting purposes only. Ownership (please check all that apply):

☐African American

☐Asian

☐Armenian

☐Hispanic

☐Native

American

☐Disabled

☐Female https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Pasadena, CA 91101

Phone (626) 744-6755 https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Project Workforce Utilization (Form AA-2)

This form is to be included in all bid documents for projects involving labor or services valued at $25,000 or more.

Instructions: Please indicate the job titles/classifications to be used in the performance of this contract should it be awarded to your firm. Please indicate the number of employees in each job classification as well as the number of new hires, if any, as a result of this contract.

Name of Company: ___________________________________________

Project:___________________________________________

Job Titles/Classification Estimated number of existing staff to be employed in this classification if awarded the contract

Estimated number of new hires to be employed in this classification if awarded the contract

Are any current employees or potential new hires Pasadena residents? If so, how many?

Pasadena, CA 91101

Phone (626) 744-6755 https://www.cityofpasadena.net/finance/doing-business-with-the-city/

Current Permanent Workforce Utilization (Form AA-3) (OPTIONAL)

Name of Company: ___________________________________________

Project: ____________________________________________________

Completion of this form is OPTIONAL. Any information supplied by Proposers is for reporting purposes only and will not be factored into the award of any contract.

Instructions: Please indicate the number of employees in each Job Classification belonging to the following groups.

White (not of Hispanic origin)

African-American (not of Hispanic origin)

Hispanic Asian/Pacific Islander

Native American

Armenian Male Female

CLASSIFICATION

Officials/Managers

Professionals

Technicians

Office/Clerical

Skilled Craft Workers

Operators (semi-skilled)

Laborers

Service Workers

TOTAL

SUBCONTRACTOR LISTING

Prime Contractors shall be governed by the provisions of the Subletting and Subcontracting Fair Practice Act (California Public Contract

Code § 4100 et seq.), and shall set forth below the name, business location, and California contractor license number of each subcontractor required to be listed and the portion of the work that will be done by each subcontractor.

Do not list alternate subcontractors for the same work. If a Prime Contractor fails to specify a subcontractor or lists more than one subcontractor for any portion of the work in excess of one-half (1/2) of one percent (1%), Prime Contractor shall be deemed to have agreed that it is fully qualified to perform and will perform that portion of the Work itself. No Prime Contractor shall substitute any person as subcontractor in place of the subcontractor listed nor shall any subcontract be assigned or transferred except as provided for in the Subletting and Subcontracting

Fair Practice Act.

Prime Contractors in violation of any of the provisions of the Subletting and Subcontracting Fair Practice Act are subject to possible cancellation of the Contract and monetary penalties as well as disciplinary action by the Contractors’ State License Board.

Bidders must designate the name, address, and trade of ALL Subcontractors required to be listed on this form and submit with their bid.

DO NOT PUT ANY MARKINGS IN THE LAST 2 COLUMNS OF THIS FORM. The City may request Bidders to submit additional information about listed Subcontractors to be provided in the blank columns within 24 hours after the City’s written request, such as: telephone number, value of work, Subcontractor references, information regarding the Bidders self-performed work, etc.

Name of Subcontractor

Business Address

Contractor License Number Trade/ Portion of

Work

Name of Bidder:

I I I I I I I

Name of Subcontractor

Business Address

Contractor License Number Trade/ Portion of Work

[Duplicate and attach additional page(s) as required.]

Name of Bidder: _________________________________________

IDENTITY CONFIRMATION

PROJECT: _______________________________________________________________

Contractor’s Name

Office Address

If an individual, so state

If a partnership, co-partnership, or firm, so state, giving the names and addresses of individuals constituting the organization.

If a corporation, give the following information:

Name of President

Name of Secretary

Organized under the laws of the State of

Name and address of local representative

Telephone

Fax

(Attach an incumbency certificate, or certificate of secretary of corporation, or corporate resolution to confirm: (1) the identity of the officer who signs the Bid; (2) the fact that he/she is the officer named; and (3) his/her authority to bind the Bidder. See attached sample forms.)

INCUMBENCY CERTIFICATE

The undersigned, Secretary/Assistant Secretary of __________________ (the “Company”), hereby certifies to the City of Pasadena (“City”) as follows:

1. That he/she is the duly elected, qualified, and acting Secretary/Assistant Secretary of the Company, and that, as such, he/she is authorized to execute this Incumbency Certificate on behalf of the Company.

2. That pursuant to the Company’s By-Laws, as amended by resolutions, the following named person(s) was/were designated and appointed to the office(s) indicated below, and that said person(s) does/do continue to hold such office(s) at this time.

NAME OFFICE/TITLE

3. That the person(s) named above is/are authorized to sign the Bid, the bid bond, the Contract performance bond and payment bond submitted or to be submitted to the City, and to enter into the Contract on behalf of the Company, and that the signature set forth on each of the documents is that of the person(s) named above.

IN WITNESS WHEREOF, the undersigned has executed this Incumbency Certificate under penalty of perjury under the laws of the State of California on

____, 20___ at ________________________ [designate location].

(Signature)

(Print or type name)

Its:

(Insert Secretary or Assistant Secretary)

CERTIFICATE OF SECRETARY OF CORPORATION

I, , Secretary of _____________________________, a corporation incorporated under the laws of the State of _____________ (“Corporation”), do hereby certify that the foregoing is a full, true and correct copy of the resolution of the Board of Directors of this Corporation, duly and validly adopted by the Board of Directors as required by law, and by the by-laws of this Corporation.

I further certify that the foregoing resolution remains in full force and effect and has not been amended or revoked, and that the specimen signatures appearing below are the signatures of the officers authorized to sign for this Corporation by virtue of the foregoing resolution.

IN WITNESS WHEREOF, I have hereunto set my hand as Secretary of the Corporation this _________ day of _______________________________, 20____.

AUTHORIZED SIGNATURES:

(Signature)

(Name) (Title)

(Signature)

(Name) (Title)

(Signature)

Secretary of __________________________, a __________________________ Corporation

RESOLUTION

WHEREAS, this Board of Directors of [name of corporation] deems it desirable and in the best interests of this Corporation and its shareholders to enter into contracts for the performance of [type of services];

NOW, THEREFORE, the Board of [name of corporation] finds and declares that conferring authority to sign bids, bid bonds, contract performance bonds and payment bonds, and to enter into contracts on behalf of [name of corporation] upon certain officers [and/or directors] of the corporation is in the best interest of

[name of corporation] and does hereby resolve, determine, and order as follows:

[Name], the [Title] [list others as appropriate] is duly authorized to sign bids, bid bonds, contract performance bonds and payment bonds, and to enter into and sign said contracts on behalf of

[name of corporation].

[Name] currently holds the [Title] and has held that office since [date] [list others as appropriate]. The [Titles] is [are] further authorized to provide such additional information and execute such other documents as may be required in connection with said contracts and to execute any amendments, rescissions, and revisions thereto.

Date Director

Date Director

Date Director

PUBLIC CONTRACT CODE DISCLOSURES

Public Contract Code Section 10285.1 Statement

Public Contract Code Section 10285.1 Statement In conformance with Public Contract Code Section 10285.1 (Chapter 376, Stats. 1985), the bidder hereby declares under penalty of perjury under the laws of the State of California that the bidder has ___ , has not ___ been convicted within the preceding three years of any offenses referred to in that section, including any charge of fraud, bribery, collusion, conspiracy, or any other act in violation of any state or Federal antitrust law in connection with the bidding upon, award of, or performance of, any public works contract, as defined in Public Contract Code Section 1101, with any public entity, as defined in Public Contract Code Section 1100, including the Regents of the University of California or the Trustees of the California State University. The term "bidder" is understood to include any partner, member, officer, director, responsible managing officer, or responsible managing employee thereof, as referred to in Section 10285.1.

Note: The bidder must place a check mark after "has" or "has not" in one of the blank spaces provided.

The above Statement is part of the Bid. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution.

NAME AND TITLE SIGNATURE AND DATE

Public Contract Code Section 10162 Questionnaire

In conformance with Public Contract Code Section 10162, the Bidder shall complete, under penalty of perjury, the following questionnaire: Has the bidder, any officer of the bidder, or any employee of the bidder who has a proprietary interest in the bidder, ever been disqualified, removed, or otherwise prevented from bidding on, or completing a federal, state, or local government project because of a violation of law or a safety regulation?

Yes _____ No _____ ________________________________________

SIGNATURE AND DATE

If the answer is yes, explain the circumstances in the following space.

Public Contract Code 10232 Statement

In conformance with Public Contract Code Section 10232, the Contractor, hereby states under penalty of perjury, that no more than one final unappealable finding of contempt of court by a federal court has been issued against the Contractor within the immediately preceding two year period because of the Contractor's failure to comply with an order of a federal court which orders the Contractor to comply with an order of the National Labor Relations Board.

Note: The above Statement and Questionnaire are part of the Bid. Bidders are cautioned that making a false certification may subject the certifier to criminal prosecution.

NAME AND TITLE SIGNATURE AND DATE

DEBARMENT AND SUSPENSION CERTIFICATION

I. PRIMARY CONTRACTOR

In accordance with Title 2 CFR, Part 180, “OMB Guidelines to Agencies on Government wide Debarment and Suspension (nonprocurement)”, the prospective bidder, under penalty of perjury, certifies the following:

A. He/she or any person associated therewith in the capacity of owner, partner, director, officer, or manager, is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any federal agency; has not been suspended, debarred, voluntarily excluded, or determined ineligible by any federal agency within the past three (3) years; does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years. Any exceptions to this certification must be disclosed to City of Pasadena;

B. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (A) of this certification;

and

C. Have not within a three-year period preceding this application/bid had one or more public transactions (Federal, State or local) terminated for cause or default.

If unable to certify any or all aforementioned statements, the Contractor shall attach an explanation to this Form.

Exceptions will not necessarily result in denial of recommendation for award, but will be considered in determining Bidder’s responsibility. Disclosures must indicate to whom exceptions apply, initiating agency, and dates of action.

Exceptions to the Federal Government Excluded Parties List System maintained by the General Services Administration are to be determined by the Federal Agency.

[Name] [Title] [Signature] [Date]

DEBARMENT AND SUSPENSION CERTIFICATION

I. LOWER TIER COVERED TRANSACTIONS (SUBCONTRACTORS)

In accordance with Title 2 CFR, Part 180, “OMB Guidelines to Agencies on Government wide Debarment and Suspension (nonprocurement)”, the lower tier entity of ___________________________ (Contractor), under penalty of perjury, certifies the following:

A. He/she or any person associated therewith in the capacity of owner, partner, director, officer, or manager, is not currently under suspension, debarment, voluntary exclusion, or determination of ineligibility by any federal agency; has not been suspended, debarred, voluntarily excluded, or determined ineligible by any federal agency within the past three (3) years; does not have a proposed debarment pending; and has not been indicted, convicted, or had a civil judgment rendered against it by a court of competent jurisdiction in any matter involving fraud or official misconduct within the past three (3) years. Any exceptions to this certification must be disclosed to City of Pasadena;

B. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (A) of this certification;

and

C. Have not within a three-year period preceding this application/bid had one or more public transactions (Federal, State or local) terminated for cause or default.

If unable to certify any or all aforementioned statements, the Subcontractor shall attach an explanation to this Form.

Exceptions will not necessarily result in denial of recommendation for award, but will be considered in determining Bidder’s responsibility. Disclosures must indicate to whom exceptions apply, initiating agency, and dates of action.

Exceptions to the Federal Government Excluded Parties List System maintained by the General Services Administration are to be determined by the Federal Agency.

Lower Tier Participant:___________________________________________

[FIRM NAME]

[Name] [Title] [Signature] [Date]

CONTRACTOR QUALIFICATION STATEMENT

GENERAL

To be considered, all information requested must be submitted on this Contractor Qualification Statement form or on sheets which clearly identify the paragraph number and subparts being responded to. Additionally, to the extent the form does not provide sufficient space to fully respond, Bidders 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 Bid will be rejected if the answer to any of questions 1 through 6 is “no,” or if the answer to any of questions 7, 8, 9, 10, or 11 is “yes.”

1. Contractor is able to obtain insurance for the Bid Package with the minimum scope and limits specified in Article 8.5 of the Agreement.

Yes No

NOTE: Be prepared to submit a specimen certificate evidencing appropriate insurance for the Bid Package, as set forth in Article 8.5 of the Agreement within 24 hours after the Bid Deadline.

2. Contractor 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

Contractor 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, which states that your current single limit bonding capacity is in excess of your Base Bid Price for your Bid Package within 24 hours after the Bid Deadline?

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 1.30 or less within 24 hours after the Bid Deadline?

Yes No

5. Have you been in business for a minimum of five (5) years under the contractors license used for the Bid you are submitting?

Yes No

6. Have you have satisfactorily completed: 1) at least three (3) prevailing wage public contract in California; and 2) at least three (3) contract comparable in scope and scale to this Project, completed within five (5) years prior to the Bid Deadline and with the dollar value of Bidder’s portion of each such project in excess of $1,500,000? (See Part II of this Contractor Qualification Statement, item 22.)

Yes No

7. Has your contractors 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 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 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?

Contractor’s Qualification Statement

PART II QUESTIONNAIRE

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 1.30 or less, or submit within 24 hours after the Bid Deadline.

6. Please 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) Facsimile No: ( )

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. Please attach a reviewed or audited financial statement for the past one (1) year, 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:

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:

Telephone No: ( )

Facsimile No: ( )

19. If other than a Corporation or Partnership, describe type of organization and name of principals:

Owner Percentage of Ownership

20. Have you ever been licensed under a different name or different license number?

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

21. Complete the following information for your current projects. (List five projects maximum and attach separate sheets. If one or zero current projects, list your two most recently completed projects.)

(a) Name of Project:

(b) Client:

(c) Project Address:

(d) Contact Name:

(e) Contact Phone: ( )

(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) Forecast/Actual Completion Date:

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

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

22. Complete the following information for completed construction contracts, including, but not limited to contracts with the City of Pasadena. (List five projects maximum and attach additional sheets as necessary. Be sure to include the mandatory qualifying Project(s) required by Section 23.1.5 of the Instructions to Bidders. Refer also to Part I of this Contractor Qualification Statement, item 6.)

(a) Name of Project Manager/Superintendent:_________________________

(b) Name of Project:

(c) Client:

(d) Project Address:

(e) Contact Phone: ( )

(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. 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:

(d) Contact Name:

(e) Contact Phone: ( )

(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:

24. Complete the following information for each project in which your organization has been involved in litigation in the last five (5) years in which the amount in controversy exceeded $25,000. 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:

25. List any projects in which your organization has been involved in any claim for 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:

(e) Parties Involved:

(f) Description of Claim:

(g) Result:

26. Complete the following information for each project in which your organization has been involved in litigation with the City. 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:

27. List any projects in which your organization has been involved in any claim for 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:

28. Has your organization ever been terminated from a project before completion? If so, please 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:

29. Has the bidder, any officer of the bidder, or any employee of the bidder who has a proprietary interest in the bidder, ever been disqualified, removed, or otherwise prevented from bidding on, 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.

Dated:

(Signature)

(Title)

DECLARATION OF ELIGIBILITY TO CONTRACT

[Labor Code Section 1777.1; Public Contract Code Section 6109]

The undersigned, a duly authorized representative of Contractor, certifies and declares that:

The undersigned contractor is aware of Sections 1777.1 and 1777.7 of the California Labor Code, which prohibit a contractor or subcontractor who has been found by the Labor Commissioner or the Director of Industrial Relations to be in violation of certain provisions of the Labor Code, from bidding on, being awarded, or performing work as a subcontractor on a public works project for specified periods of time.

The undersigned Contractor is not ineligible to bid on, be awarded or perform work as a subcontractor on a public works project by virtue of the foregoing provisions of Sections 1777.1 or 1777.7 of the California Labor code or any other provision of law.

The undersigned contractor is aware of California Public Contract Code Section 6109, which states:

A public entity, as defined in Section 1100 [of the Public Contract Code], may not permit a contractor or subcontractor who is eligible to bid or work on, or be awarded, a public works project pursuant to Section

1777.1 or 1777.7 of the Labor Code to bid on, be awarded, or perform work as a subcontractor on, a public works project. Every public works project shall contain a provision prohibiting a contractor from performing work on a public works project with a subcontractor who is ineligible to perform work on the public works project pursuant to Section 1777.1 or 1777.7 of the Labor Code.

Any contractor on a public works project entered into between a contractor and a debarred subcontractor is void as a matter of law. A debarred subcontractor may not receive any public money for performing work as a subcontractor on a public works contract, and any public money that may have been paid to a debarred subcontractor by a contractor on the project shall be returned to the awarding body. The contractor shall be responsible for the payment of wages to workers of a debarred subcontractor who has been allowed to work the project.”

The undersigned contractor has investigated the eligibility of each and every subcontractor the undersigned contractor intends to use on this public works project, and determined that none of them is ineligible to perform work as a subcontractor on a public works project by virtue of the foregoing provisions of the Public Contract Code, Sections 1777.1 or 1777.7 of the Labor Code, or any other provision of law.

The undersigned declares under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed this _____ day of ___________, _______ at _____________________________________, California.

Name:

Title:

Signature:

Company:

Substitution/Value Engineering Request Form

Project: ________________________________________________________

Location(s): ________________________________________________________

TO: City: City of Pasadena Architect: ________________

FROM:

Request for Substitution/Value Engineering and Substantiation for Request:

1. Section, Paragraph and Page Number of Technical Specifications to which this Request applies:

2. Item specified for which substitution is requested:

Name or Brand:

Manufacturer:

Catalog No.:

Underwriters’ Laboratory and/or ICBO No.:

3. The proposed substitution is:

Name or Brand:

Manufacturer:

Catalog No.:

Underwriters’ Laboratory and/or ICBO No.:

4. Contractor is required to provide product data for the proposed substitution consisting of the description of the product or item, reference standards and performance test data, together with substantiating data. No substitution request will be considered by the City without such data and substantiation. Attached hereto is complete technical data, including technical information, complete manufacturer’s catalogs, brochures and drawings, certified laboratory test reports and samples as applicable for the proposed substitution, installation and operating instructions, manufacturing warranties and other descriptive material. Reasons for substitution request:

5. Detailed comparison of significant qualities and properties (size, weight, durability, performance and similar characteristics) including the visual effect where applicable, for the proposed substitution in comparison with original requirements includes (list detailed comparison with supporting data, use separate sheets if required):

6. Installation changes and changes to Drawings and Technical Specifications required by the proposed substitution are (list all required changes, use separate sheets if required):

7. Does this substitution affect dimensions shown on Drawings?

If yes, clearly indicate changes on each Drawing by Sheet No.:

8. List the effects of the proposed substitution on other parts of the Work or on separate contracts, including required changes in Drawings, dimensions, engineering and detailing costs and effect on other trades.

9. What effect does substitution have on applicable code requirements?

10. Identify differences between the proposed substitution and the specified item.

11. Attach a copy of manufacturer’s warranty; manufacturer’s guarantees and warranties of proposed and specified items are:

Same

Different

(Explain on attachment.)

Manufacturer shall provide a letter stating the fitness for intended use, and performance equivalence with the specified item.

12. List the name and address of three similar projects (not necessarily installed by

Contractor) on which the proposed product was used and date of installation:

1. Name of Project:

Date of Installation:

2. Name of Project:

3. Name of Project:

13. Use of the substitution will cause the Contract Time to be:

Same

Different (Explain on attachment.)

14. Use of the substitution will affect the critical path of the Construction Schedule as follows

(identify any proposed adjustment to the Contract Time):

15. Adjustment, if any, in the Contract Sum of $ will result from use of the substituted item.

16. Estimated cost of any engineering, design or agency fees required for work of all trades directly or indirectly affected by the substitution is: $ .

17. The date by which City must accept this Request in order for the time and cost estimates in Paragraphs 14 and 16 to remain valid is:

18. Contractor Affidavit. The undersigned, having thoroughly investigated the proposed substitution represents, certifies and declares, under penalty of perjury under the laws of the State of California that:

(1) Contractor has personally investigated the proposed substitution and determined that it is equal or superior in all respects to that specified except as specifically noted ;

(2) Contractor will provide the same warranty and correction responsibility for the proposed substitution that the Contractor would have provided for that specified;

(3) The cost data presented is complete and includes all related costs under this Contract except any redesign costs and agency fees;

(4) Contractor will pay redesign, engineering, detailing and special inspection costs caused by the use of this substitution;

(5) Contractor will coordinate the installation of the accepted substitution, making such changes as may be required for the Work to be complete in all respects.

(6) Contractor waives all claims for additional costs relating to the substitution which has subsequently become apparent; and

(7) Contractor assumes all responsibility for direct or indirect costs and/or time impacts as a result of the use of the substitution.

Submitted by:

(Signature)

For use by City:

___ Accepted ___ Accepted as noted

___ Not Accepted ___ Rejected as late

(Firm)

(By)

(Address)

(Date)