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DESIGN-BUILDERPREQUALIFICATION QUESTIONNAIREPROGRESSIVE DESIGN-BUILD DELIVERYPROJECT NO. M050465REPLACEMENT HOSPITAL TOWERMandatory Prequalification Conference:2:00 pm November 13, 2019Prequalification Questionnaire Due Date:4:00 pm December 5, 2019Facilities Design & ConstructionQuestions to FD&C Contracts:4800 2nd Avenue, Suite 3010Leila Couceiro, Contracts ManagerSacramento, CA 95817lccouceiro@ucdavis.edu QUESTIONNAIRE – DESIGN-BUILDERReplacement Hospital TowerProject No.: M050465FACILITIES DESIGN AND CONSTRUCTIONUC DAVIS HEALTHSACRAMENTO, CALIFORNIAEach prospective Proposer must have the appropriate contractor’s license required by the State of California and must complete and submit all portions of this Prequalification Questionnaire. Each prospective Proposer must answer all applicable questions and provide all requested information. Any prospective Proposer failing to do so may, at the sole discretion of the University of California, be deemed to be not responsive and not responsible with respect to this Prequalification, and its bid rejected.The undersigned declares under penalty of perjury that the Prequalification information submitted with this form is correct, complete and not misleading and that this declaration was executedin FORMTEXT ?????County, California, on FORMTEXT ????? FORMTEXT ?????(Proposer Name) FORMTEXT ?????(Name and Title of Proposer’s Contact Person for Questions) FORMTEXT ?????(Address) FORMTEXT ?????(City, State, Zip Code) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(Telephone Number)(Fax Number)(Email Address)(Signature) FORMTEXT ?????(Typed Name and Title)Each prospective Proposer must answer all of the following questions and provide all requested information, where applicable. Any prospective Proposer failing to do so may be deemed to be not responsive and not responsible with respect to this prequalification at the sole discretion of the University of California. All information submitted for prequalification evaluation will be considered official information acquired in confidence, and the University of California will maintain its confidentiality to the extent permitted by law. Any prospective Proposer found to be not prequalified as a result of the Proposer's answers to this Prequalification Questionnaire will receive written response from the University Facility explaining the Facility's decision. If the Proposer can refute some of the facts upon which the decision was based, the Proposer can request a hearing at the Facility to appeal the decision. The appeal shall state the basis of the appeal and must be submitted in writing within 3 working days of receipt of notification and must request a written response or hearing from University. The decision of the Facility is final and not appealable within the University of California.The Progressive Design-Build contract will require the successful Proposer to provide both design and construction services. The entity that provides these services is the Proposer, but the actual structure of the entity is up to each Proposer. The Proposer may, as an example, be a construction company, may be a joint venture between construction companies, or an independent contractor. All information required herein shall be submitted within the following parameters:1.The Proposer shall hold all required licenses and DIR registration.2.The Proposer shall be the financially responsible entity for bonding and insurance. TOC \o "1-3" \h \z \u PREQUALIFICATION QUESTIONNAIRE – DESIGN-BUILDER PAGEREF _Toc19783873 \h 2I.GENERAL PAGEREF _Toc19783874 \h 1A.Progressive Design-Builder Prequalification PAGEREF _Toc19783875 \h 1B.Project Description PAGEREF _Toc19783876 \h 1C.Project Delivery PAGEREF _Toc19783878 \h 1D.Selection of Design-Build Team PAGEREF _Toc19783879 \h 2E.Design-Build Subcontractors PAGEREF _Toc19783880 \h 2F.Target Cost PAGEREF _Toc19783881 \h 2G.Project Timing PAGEREF _Toc19783882 \h 2H.Prequalification Process PAGEREF _Toc19783885 \h 2I.Prequalification Questionnaire Availability PAGEREF _Toc19783886 \h 3J.Mandatory Prequalification Conference PAGEREF _Toc19783899 \h 3K.Submittal Procedures and Deadline PAGEREF _Toc19783905 \h 3L.Rating and Evaluation Procedures PAGEREF _Toc19783906 \h 3M.Joint Ventures PAGEREF _Toc19783975 \h 4N.University Controlled Insurance Program (UCIP) PAGEREF _Toc19783976 \h 5II.PREQUALIFICATION QUESTIONNAIRE – REQUIRED ELEMENTS PAGEREF _Toc19783977 \h pany Name and Address PAGEREF _Toc19783978 \h 6B.Contact Information PAGEREF _Toc19783979 \h 6C.Entity Submitting this Prequalification Questionnaire PAGEREF _Toc19783980 \h 6D.Type of Business Organization PAGEREF _Toc19783981 \h 6E.Year Company was Established PAGEREF _Toc19783985 \h 7F.Parent Company Information PAGEREF _Toc19783986 \h 7G.List All Former Company Names PAGEREF _Toc19783987 \h 7H.License and Registration with California DIR PAGEREF _Toc19783988 \h 7I.Contractor’s License Board Disciplinary Proceedings PAGEREF _Toc19783989 \h 9J.Debarment PAGEREF _Toc19783990 \h 9K.Labor Code Violations PAGEREF _Toc19783991 \h 9L.Surety PAGEREF _Toc19783993 \h 9M.Financial Capability PAGEREF _Toc19783994 \h 10N.Financial Data PAGEREF _Toc19783996 \h 10O.Insurance PAGEREF _Toc19783999 \h 11P.Experience Modification Rate PAGEREF _Toc19784000 \h 12Q.Qualification History PAGEREF _Toc19784001 \h 12R.Unsettled Warranties or Claims PAGEREF _Toc19784002 \h 12III.CONSTRUCTION EXPERIENCE PAGEREF _Toc19784003 \h 14A.Years of Experience PAGEREF _Toc19784004 \h 14B.Project Completion PAGEREF _Toc19784005 \h 14C.Liquidated Damages PAGEREF _Toc19784006 \h 14D.Supplemental Company Information PAGEREF _Toc19784007 \h 141.Safety Program PAGEREF _Toc19784008 \h parable Project Experience PAGEREF _Toc19784009 \h 14F.Proposed Design-Build Team Members / Key Personnel PAGEREF _Toc19784021 \h 15IV.EVALUATION SCORING PAGEREF _Toc19784022 \h 16V.CLAIMS HISTORY PAGEREF _Toc19786570 \h 19A.Owner Against Contractor Claim PAGEREF _Toc19786571 \h 19B.Contractor Against Owner Claim PAGEREF _Toc19786572 \h 19VI.REQUIRED COMPLETED ATTACHMENTS PAGEREF _Toc19786573 \h 21VII.DECLARATION PAGEREF _Toc19786574 \h 22[THIS SPACE LEFT INTENTIONALLY BLANK]GENERALProgressive Design-Builder PrequalificationThis prequalification is for a general contractor who, after selection, will assume the role of a Design-Builder once the Architect has been selected per the process described below. The University intends to use a Progressive Design-Build agreement to deliver this Project. The Design-Build contract will require the successful Proposer to enter into a contract with UC Davis Health and to provide both design and construction services. The University's primary objective in utilizing the Progressive Design-Build approach is to bring the best available integrated design expertise and construction experiences to this Project. The University has determined that proposers on this project must be prequalified. Prequalified proposers will be required to have the following California contractor’s license(s): B - General Building Contractor. Project Description The University of California Davis Medical Center (UCDMC), located in Sacramento, is the teaching hospital for UC Davis Health (UCDH). In order to meet California’s 2030 seismic safety standards and the hospital’s operational needs, and in accordance with the UCDH Long Range Development Plan (LRDP), UCDH has developed a Clinical Services Master Plan to identify market needs, bed and key service needs, preliminary building configurations drawings to test fit on the site, and established preliminary costs of the proposed replacement hospital. Resulting from this planning effort, UC Davis Health is anticipating the development and construction of a new Replacement Hospital Tower (RHT). The Replacement Hospital Tower is a key piece of the strategy to achieve seismic safety compliance, additional service capacity, and operational improvements. The RHT project is envisioned to comprise 200 - 350 inpatient beds including ICU, medical/surgical, pediatric services, and/or universal rooms, as well as imaging and support services. The building options under consideration range from 600,000 to 800,000 BGSF of new space, plus approximately 10,000 BGSF of renovation. The proposed site is located on the east end of the existing hospital, adjacent to the Pavilion that houses primarily surgery, ICUs, the burn unit, and the emergency department. The RHT will be connected to the Pavilion. Utilities for the RHT will be supplied from the Central Utilities Plant. The RHT will be designed to maximize operational efficiency and include the flexibility to accommodate future health care technologies. Excellence in the design and construction of the RHT will reflect UCDH’s central role as the premier health care provider in Sacramento and the Central Valley of California. A space and functional program has been completed by the University and will be included with the Request for Proposals issued to the successful qualified proposers. Design is planned to commence in mid-2020 and the targeted completion date for the project is 2027. The estimated (current dollars 10/2019) construction cost, inclusive of design and pre-construction services with fees, ranges from $860 million to $1.0 billion. The estimated (escalated) construction cost, inclusive of design and pre-construction services with fees, ranges from $1.0 billion to $1.5 billion. The Project Target Value will be established at the onset of the project and will be the maximum amount the University will spend on the Project. The planning and design of the RHT Project must meet the Target Value Cost of the project and the project team must follow the Target Value Design approach. UCDH will manage the Architect selection process by establishing a short-list of Architects and will collaborate with the Design-Builder in the final selection of the Architect. After the selection, the Architect will enter into a contractual arrangement with the Design-Builder for design services. Project DeliveryThe selected Design-Builder will provide Schematic Design including Program Validation, Design Development and Construction Documents for the project, including but not limited to, architectural, structural, civil, geotechnical, mechanical, plumbing, electrical, telecommunication, landscape, interdisciplinary construction coordination drawings as well as engineering calculations, including site, utilities, structural, mechanical and electrical systems necessary for a complete Project. Additionally, the successful Proposer shall be responsible for performing all work required to construct the Project as described and specified in the Contract Documents, including but not limited to, site preparation, site utilities, utility connections, buildings, hardscape and landscape, and surface improvements. The Project will require the Design-Builder’s team, including the Design-Builder, all design consultants, design-build subcontractors and other subcontractors working on the Project (Design-Build Team) be co-located for the duration of their work at the UCDH Project Big Room.UCDH will use the Best Value Selection process based on price and qualifications. The price elements will include percentages for overhead and profit and rates for professional services and general conditions personnel. Qualifications will be determined by the information given in the attached Level 1 Qualification Forms.Selection of Design-Build TeamPrior to the Design-Builder being contracted with the University, the University will issue a Request for Qualifications (RFQ) for Architectural services. The selection process will include screening all applicants and shortlisting at least three (3) firms in accordance with University policies and procedures. Once a Notice of Intent to award is issued to the Design-Builder, the University and Design-Builder will collaboratively select the Architect of Record (Architect). The Architect will be under contract with the Design-Builder. Design-Build, Design-Assist, and other specialty subconsultants shall be selected with participation and agreement by the University. Selection process details will be outlined on the Request for Proposals that will be issued to the short-listed Proposers. The University will contract directly with the Medical Equipment consultant. Design-Build SubcontractorsAfter execution of the contract, Design-Builder shall comply with the bidding requirements set forth in Public Contract Code section 10500-10506 and Public Contract Code section 4100, et seq., for procurement of Subcontractors. In addition, the Design-Builder shall collaborate with the University Representative regarding the evaluation of bidder prequalification and bid analysis to determine the best Subcontractors suited for the Project based on the criteria established in the Request for Proposals. Target Cost The Target Cost (inclusive of preconstruction, design and construction cost) will be included in the Request for Proposal (RFP) and it will be the maximum amount the University will spend on the project.Project TimingThe Project will proceed in three phases: Phase 1:Schematic Design and Design Development DocumentsPhase 2:Construction DocumentsPhase 3:ConstructionThe Project will commence with an Intent to Award, selection of the Architect, and Notice to Proceed (NTP) for Phase 1 immediately upon award of the Contract. The University Milestone Schedule shows 36 months for the completion of Phases 1 and 2, and 48 months for Phase 3 including Commissioning.Prequalification ProcessThe purpose of the Prequalification Process is to establish a shortlist of highly qualified Design-Build Contractors to receive the Request for Proposals (RFP) for the project. The prequalification process is a two-step process: Level 1 – Submittal of Prequalification documents, and Level 2 – an Interview. This process will result in the selection of a pre-qualified shortlist of companies receiving the RFP. Level 1 (Submittal of Prequalification Documents): Prospective proposers must meet the minimum prequalification requirements and will be scored based on the pre-established rating system described on this Questionnaire. The top five (5) scorers will be deemed prequalified to proceed to Level 2, the Interview. The University may interview more than five (5) proposers at its discretion.Level 2 (Interview): Proposers will be notified whether they have been selected for a Level 2 Prequalification Interview and if submission of any additional clarifying information is required. The results of the Level 2 Interview and materials submitted in Level 1 will be separately scored. The top three (3) scoring teams established at the completion of Level 2 will be invited to participate in the Level 3 RFP competition. Proposers will be notified by email whether or not they are prequalified to move on to Level 3. Level 3 (RFP competition and presentation): Prequalified proposers receive the RFP and will then submit cost and technical proposals. The cost submittal that is part of the RFP will consist of a percentage for fee for the construction work, and rates for professional services during design and preconstruction, including rates for General Conditions Personnel during Construction. The final presentation, as well as the technical proposals, will be scored according to an established scoring system. The price will be divided by the score to determine a price per point. The prequalified proposer with the lowest price per point will be the apparent low proposer for the Project. There is no appeal process once the University has determined a team is not prequalified. Only those Proposers who pass Level 2 prequalification process and are among the top three (3) scorers will be eligible to participate in the Level 3 competition.Prequalification Questionnaire AvailabilityProvide all requested information, as applicable, on the questionnaire. Any prospective Proposer failing to do so may be deemed non-responsive with respect to the prequalification process for this project. All information submitted for prequalification evaluation will be considered official information acquired in confidence, and the University will maintain its confidentiality to the extent permitted by law.Editable copies of the Prequalification Questionnaire will be available at our website () beginning on Thursday, October 24, 2019. Mandatory Prequalification ConferenceProposers interested in prequalifying to propose on this project are required to attend the Mandatory Prequalification Conference on Wednesday, November 13, 2019 beginning promptly at 2:00 PM. Participants shall meet at: UC Davis Health, Center for Health and Technology, 4610 X Street, Room 1341, Sacramento, CA 95817.Any Proposer failing to sign in on the official attendance sheet at the pre-qualification conference will not be eligible to participate in the prequalification process. Prospective Proposers arriving after the Pre-qualification Conference meeting start time of 2:00 PM will be automatically disqualified from submitting proposals for this project. Please plan to arrive approximately 45 minutes prior to the meeting to allow time for parking. Free parking is available at the Contractor’s Parking Lot or paid parking at Parking Structure III (see our website for locations).Submittal Procedures and DeadlineProposers interested in prequalifying to propose on this project must submit a completed Prequalification Questionnaire. The University is not responsible for any costs that Proposers may incur to complete the prequalification process. All applicable portions of the attached forms shall be completed with attachments if the space provided on the questionnaire is not sufficient. Questionnaires failing to clearly present all of the requested information, or THAT ARE NOT in the format requested may be considered non-responsive and rejected on that basis. Each copy of the submittal must be complete and fully responsive to the requirements of the Prequalification Questionnaire.Prequalification Questionnaires must be received at: Facilities Design & ConstructionUC Davis HealthAttn: Contracts Group4800 2nd Avenue, Suite 3010Sacramento, CA 95817Provide one (1) original copy, (9) Bound copies, and one (1) electronic (Flash Drive) copy of the Prequalification Questionnaire. Submittals must be received at the above address no later than 4:00 PM, Thursday December 5, 2019.Prequalification Questionnaires must be submitted bound with tabs indicating all appropriate sections. Attachments must be placed behind the appropriate tabs. The front of the submission must indicate the Proposer’s name and address using the following format:PREQUALIFICATION QUESTIONNAIRECompany Name and AddressProject No.: M050465Replacement Hospital Tower Due Date and Time: 4:00 PM, Thursday December 5, 2019.Proposers shall assume full responsibility for timely delivery at the location designated for receipt of Prequalification Questionnaires. Oral, telephonic, facsimile, telegraphic, or emailed Prequalification Questionnaires are invalid and will not be accepted. No prequalification documents will be accepted after the due date and time stipulated above. SUPPLEMENTAL DATA OR ADDITIONAL PROJECT INFORMATION WILL NOT BE ACCEPTED AFTER THE DUE DATE AND TIME UNLESS SPECIFICALLY REQUESTED BY THE UNIVERSITY.Rating and Evaluation ProceduresTo be considered for prequalification, a prospective Proposer must have:CONSTRUCTION EXPERIENCE: Have sufficient project experience for the Contractor as referenced in Item III.E The projects submitted will receive points based on the extent to which they meet the listed criteria.KEY PERSONNEL: Demonstrate adequate experience for Contractor Team Key Personnel as referenced in Item III.F (information submitted will receive points based on experience).LICENSE: Hold the proper license(s) in good standing, current and active.SURETY: Submit a notarized statement from the proposed surety(ies) that states:Contractor’s current available bonding capacity meets or exceeds the minimum capacity described in the Questionnaire. (Must meet or exceed estimated project cost.)Contractor’s total bonding capacity.Surety(ies) proposed to be used on the project is an admitted surety insurer as defined in the California Code of Civil Procedure Section 995.120.Surety (ies) acknowledges its intent to provide bonding of the Project in the event Contractor is awarded the Project. INSURANCE: Submit a written declaration from its insurance agent/broker/carrier stating that the Contractor is able to obtain insurance that meets or exceeds the limits and ratings required for this project. Submit a copy of Contractor’s insurance certificate.ANNUAL REVENUE (Financial Data): Have annual revenue, averaged over the last 3 years (2016, 2017, 2018) equal to or greater than $900,000,000.declaration: Certify that all requested information is current, accurate, and complete.To be considered for prequalification, a prospective Contractor, including any proposed joint venture partners, must not have:EXPERIENCE MODIFIER RATE: An Experience Modifier Rate (EMR: Workers’ Comp) injury rating less than 1.0 for five (5) or more of the past ten (10) years.SURETY: A surety required to complete work on any contract within the past ten (10) years.CONTRACTOR LICENSE BOARD DISCIPLINARY PROCEEDINGS: A Contractors State License Board disciplinary action in the past ten (10) years. LABOR CODE VIOLATIONS: Willful Labor Code violations including, but not limited to, repeated or willful violations of applicable laws and/or regulations pertaining to the payment of prevailing wages or employment of apprentices during the past ten (10) years.CLAIMS HISTORY: A claim filed against it that meets the parameters specified in Item V.A, and have not filed a claim against an Owner that meets the parameters specified in Item V.B.UNSETTLED WARRANTIES OR CLAIMS: Any unsettled/pending claims, demands, or notices of default issued against the contractor or joint venture partners by the University of California on any University project.Contractor will be evaluated on the following additional criteria:1.FINANCIAL DATA. A desired financial current ratio of at least 1.0 for current assets to current liabilities (cash, accounts receivable net of allowance for uncollectible receivables) / (accounts payable, current portion of long term debt), and has a debt to equity ratio less than 1.0,The University will deem Contractors with poor financial standing not qualified.2.OWNER PERFORMANCE REFERENCES: the University may find a prospective Contractor not qualified if the University receives poor owner performance references on other projects. After review of the Prequalification Questionnaire, the University may request clarifying information. The Questionnaire must be complete and address all the stated requirements. Responses such as “N/A” are not acceptable. If not applicable, state “Not Applicable” and explain why. If none, state “NONE”. Do not leave any spaces blank.Contractors selected for interviews will be notified in writing, which will specify the date, time, and location of their interviews and outline the interview process. The University reserves the right to re-open the Contractor prequalification process if the University determines that there are insufficient prequalified Contractors to support the Proposal process.Joint VenturesIf two entities intend to form a Joint Venture for the purpose of executing the work on the Project, they must state their intentions on the Prequalification Questionnaire Form. Each entity of the proposed Joint Venture must submit a separate and independent set of the Prequalification Questionnaire forms. To be considered, each entity must meet all the requirements in Section I, item L. Rating and Evaluation Procedures. Section II, Item L Surety, shall be submitted on one of the two applicants’ forms completely documenting the stated requirements by a qualified Surety. Requests of Design-Builder Joint Ventures to prequalify for this project will not be considered after close of acceptance of prequalification questionnaires unless the University decides that it is in its best interest to reopen the prequalification process in a manner stated in the prequalification questionnaire.University Controlled Insurance Program (UCIP)The University has determined that this project will be covered under the University Controlled Insurance Program, or “UCIP.” The UCIP is a single insurance program that insures the University of California, Enrolled Contractors, Enrolled Subcontractors, and other designated parties (“Contractors”) for Work performed at the Project Site. Certain Contractors or Subcontractors may be excluded from the UCIP. Details of this program are contained in The Regents of the University of California UCIP Insurance Manual. Coverage under the UCIP includes Workers’ Compensation/Employer’s Liability, General Liability, and Excess Liability. The Regents of the University of California are covered under the General and Excess Liability policies. Contractors are covered under the Workers’ Compensation/Employer’s Liability and General and Excess Liability policies. The University of California will pay the insurance premiums for the UCIP coverages described in the UCIP Insurance Manual. When the University includes UCIP coverage on a project, each proposer is required to submit a bid net of all insurance costs for coverages provided by the University of California. When the solicitation documents are assembled in the resulting bid package, UCIP project insurance will be covered in Article 11.1 of the General Conditions, with project specific details provided in the UCIP Insurance Manual, provided as an exhibit. [THIS SPACE LEFT INTENTIONALLY BLANK]PREQUALIFICATION QUESTIONNAIRE – REQUIRED ELEMENTSAll information requested must be furnished on the forms provided below and must be completed in order to prequalify. Proposer must pass the following requirements to be considered pany Name and AddressCompany Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TelephoneEmailStreet Address: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeContact InformationContact Person #1: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name, TitleTelephoneEmailContact Person #2: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Name, TitleTelephoneEmailEntity Submitting this Prequalification QuestionnaireParent Company: FORMCHECKBOX FORMCHECKBOX Subsidiary: FORMCHECKBOX FORMCHECKBOX Other: FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????(Please list)Branch Office: FORMCHECKBOX FORMCHECKBOX Division: FORMCHECKBOX FORMCHECKBOX Type of Business Organization Corporation: FORMCHECKBOX FORMCHECKBOX State of Incorporation: FORMTEXT ?????Partnership: FORMCHECKBOX FORMCHECKBOX Joint Venture: FORMCHECKBOX FORMCHECKBOX Sole Proprietorship: FORMCHECKBOX FORMCHECKBOX Other: FORMCHECKBOX FORMTEXT ?????(Please list)Total number of employees on payroll in the corporation: FORMTEXT ?????Total number of employees on payroll in the local office submitting this prequalification: FORMTEXT ?????Principal Office (if different from above): FORMTEXT ?????Street Address FORMTEXT ?????President’s Name: FORMTEXT ?????City, State & Zip Code If a partnership, provide the following information:Date of Organization: FORMTEXT ?????General: FORMCHECKBOX Association: FORMCHECKBOX Name and complete legal address of each general partner: FORMTEXT ????? FORMTEXT ?????(Partner’s Name)(Legal Address) FORMTEXT ????? FORMTEXT ?????(Partner’s Name)(Legal Address)If a Joint Venture, provide the above information for the financially responsible party.If more space is needed, provide the information on your company’s letterhead with reference to the project name and number, and attach it to this QuestionnaireYear Company was EstablishedYear established: FORMTEXT ?????Parent Company Information Company Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TelephoneWebsiteStreet Address: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeContact Person: FORMTEXT ????? FORMTEXT ?????Name, TitleTelephoneList All Former Company Names FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????License and Registration with California DIR Proposer must have a current and active California State Contractors license in good standing with a B - General Building Contractor classification for this Project. Proposer must also be registered with the Department of Industrial Relations (DIR) pursuant to Labor Code section 1725.5 and 1771.1. For Joint Venture applications by two or more licensees, the Joint Venture entities must submit a written commitment to obtain the proper California joint venture license by the Prequalification Questionnaire submittal deadline, and at least one entity of the joint venture must have a proper license in good standing that is current and active upon submission of the Design-Builder Prequalification Questionnaire. The letter of commitment must include:Name, address, and phone number of the Joint Venture as it will appear on the records of the Contractors State License BoardName, address, and telephone number of each entity comprising the Joint Venture as it appears on the records of the Contractors State License BoardName of the Responsible Managing Officer of the Joint VentureOrganizational chart of the Joint VentureSignatures of the Responsible Managing Officers for each entity comprising the Joint VentureNOTE: The entity submitting this Prequalification Questionnaire must be the holder of the requisite licenseALL LICENSES AND REGISTRATION MUST BE MAINTAINED IN GOOD STANDING, CURRENT AND ACTIVE THROUGHOUT THE PROJECT.Does your firm have the required California State Contractors license?Yes FORMCHECKBOX No FORMCHECKBOX Is your firm registered with the Department of Industrial Relations (DIR)?Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ?????(Name of Licensee as it appears on record with the California Contractors State License Board)License No. FORMTEXT ????? FORMTEXT ?????Issue Date: FORMTEXT ?????Expiration Date: FORMTEXT ?????License Class/Classes: FORMTEXT ?????Description of Classification(s): FORMTEXT ?????Description of Certification(s): FORMTEXT ?????DIR Registration No.: FORMTEXT ?????For Joint Venture: List Joint Venture entity’s license information above as the Design-Builder and the information for the proposed Joint Venture license in the space below:License No. FORMTEXT ?????Issue Date: FORMTEXT ?????Expiration Date: FORMTEXT ?????License Class/Classes: FORMTEXT ?????Description of Classification(s): FORMTEXT ?????DIR Registration No.: FORMTEXT ?????Has the above contractor license(s) been suspended or revoked by the California Contractors State License Board within the past ten years?Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX If yes, please explain: FORMTEXT ?????Contractor’s License Board Disciplinary ProceedingsHas your company, during the past ten years, received any disciplinary action from the California Contractors State License Board?Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX If yes, give details including dates: FORMTEXT ?????DebarmentIs your company currently debarred by any Federal, State or local agency?Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX If yes, give details including dates: FORMTEXT ?????Labor Code ViolationsHas your company, during the past ten years, received a determination by a court or an administrative agency of any Labor Code violations including, but not limited to, laws and/or regulations pertaining to the payment of prevailing wages or employment of apprentices on public works projects?Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Determinations by a court or an administrative agency of a violation of laws and/or regulations pertaining to the payment of prevailing wages or employment of apprentices on public works projects due to the mistake, inadvertence or neglect of your organization may be grounds for disqualification if there are three or more such determinations during the past ten years.If yes, give details including dates: FORMTEXT ?????SuretyList below all Surety companies used by your company within the past ten (10) years and state whether the Surety had to complete any part of your work including, but not limited to, warranty-related repairs or other defective workmanship on any contract within the past ten years: Surety Company #1: FORMTEXT ????? FORMTEXT ?????Surety’s NameTelephone FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip Code FORMTEXT ?????Has listed Surety Company #1 completed work for your Company within the past ten years? Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX Period CoveredSurety Company #2: FORMTEXT ????? FORMTEXT ?????Surety’s NameTelephone FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip Code FORMTEXT ?????Has listed Surety Company #2 completed work for your Company within the past ten years? Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX Period CoveredSurety Company #3: FORMTEXT ????? FORMTEXT ?????Surety’s NameTelephone FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip Code FORMTEXT ?????Has listed Surety Company #3 completed work for your Company within the past ten years? Yes FORMCHECKBOX FORMCHECKBOX No FORMCHECKBOX Period CoveredIf more space is needed, provide the information on your company’s letterhead with reference to the project name and number, and attach it to this QuestionnaireFinancial CapabilityAttach a notarized statement from the surety(ies) that states: (i) current available bonding capacity meets or exceeds the Target Cost; (ii) total bonding capacity; (iii) Surety(ies) proposed to be used on the project is an admitted surety insurer as defined in the California Code of Civil Procedure Section 995.120; and (iiii) Surety(ies) acknowledges its intent to provide bonding of the Project in the event Proposer is awarded the Project. Financial DataProvide your company’s Total Revenue, Net Income, Current Assets, Current Liabilities, Total Debt, and Total Net Worth for the past three (3) fiscal years. Specify your company’s total and current available bonding capacity. Provide the most current fiscal year data available.1. Total Revenue (past 3 fiscal years):Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Net Income (past 3 fiscal years):Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Current Assets (past 3 fiscal years):Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Current Liabilities (past 3 fiscal years):Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Total Debt (past 3 fiscal years):Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Total Net Worth (past 3 fiscal years):Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ?????Year Ending FORMTEXT ?????$ FORMTEXT ????? 7. Total Bonding Capacity$ FORMTEXT ????? 8. Total Available Bonding Capacity$ FORMTEXT ?????Financial Statement(s): Provide copies of audited Profit and Loss Statements for the past three years of operation. InsuranceWhile on-site Work will be covered under the University Controlled Insurance Program, or “UCIP,” the Proposer wishing to prequalify hereunder is required to furnish certificates of insurance on University’s form evidencing that it shall furnish and maintain Commercial Form of General Liability, Excess Liability (if applicable), Contractor‘s Professional Liability, Business Automobile Liability, Pollution Liability, and Workers’ Compensation insurance in the amounts below.The insurance required for Commercial Form General Liability, Excess Liability, Contrractor’s Professional Liability, Business Automobile Liability, and Pollution Liability Insurance shall be issued by companies with a Best rating of A- or better, and a financial classification of VIII or better (or an equivalent rating by Standard & Poor or Moody’s) written for not less than the following:Commercial Form General Liability Insurance – Limits of LiabilityMinimum RequirementsEach Occurrence - Combined Single Limit for Bodily Injury and Property Damage:$5,000,000Products-Completed Operations Aggregate:$5,000,000Personal and Advertising Injury:$5,000,000General Aggregate:$5,000,000Professional (Errors and Omissions) Liability – Limits of LiabilityMinimum RequirementContractor’s Professional Liability (Each Occurrence & Aggregate)$2,000,000Business Automobile Liability Insurance – Limits of LiabilityMinimum RequirementEach Accident - Combined Single Limit for Bodily Injury and Property Damage: $1,000,000Contractor’s Pollution Liability Insurance – Limits of LiabilityMinimum RequirementsEach Occurrence:$2,000,000Products-Completed Operations Aggregate:$2,000,000General Aggregate:$2,000,000Workers’ Compensation – As required by Federal and State of California lawEmployer’s Liability – Limits of LiabilityMinimum RequirementsEach Employee:$1,000,000Each Accident:$1,000,000Policy Limit:$1,000,000Excess/Umbrella – Limits of LiabilityMinimum RequirementsEach Occurrence:$10,000,000Aggregate:$10,000,000For those not covered under UCIP, Insurance required for Workers’ Compensation and Employer’s Liability Insurance shall be issued by companies that have a (i) Best rating of B+ or better, and a financial classification of VIII or better (or an equivalent rating by Standard & Poor or Moody's) or (ii) that are acceptable to the University. Such insurance shall be written to be not less than the amount required by Federal and State of California law.1.Is your firm able to obtain the insurance in the required limits and ratings from companies that meet the criteria stated above? Yes FORMCHECKBOX No FORMCHECKBOX 2.If “yes,” provide declaration(s) from your insurance agent/broker/carrier stating that your firm is able to obtain insurance coverage in the limits and ratings stated above from the insurance companies required for this Project.3.Provide a copy of your company’s insurance certificate.Experience Modification RateList your company’s Workers’ Compensation Experience Modifier Rate for the past ten years:2009: FORMTEXT ?????2010: FORMTEXT ?????2011: FORMTEXT ?????2012: FORMTEXT ?????2013: FORMTEXT ?????2014: FORMTEXT ?????2015: FORMTEXT ?????2016: FORMTEXT ?????2017: FORMTEXT ?????2018: FORMTEXT ?????Submit a letter from your Workers’ Compensation carrier showing your Experience Modification rate for the past five years.If the Modification Rate has been above 1.0 for five or more of the past ten years, provide an explanation, including dates: FORMTEXT ????? Qualification HistoryProvide the following information if Proposer has not qualified to perform work for the University of California:UC Campus Name: FORMTEXT ?????Facility’s Contact Person: FORMTEXT ?????Project Name: FORMTEXT ?????Project Number: FORMTEXT ?????Date of Notice of Failure to Qualify: FORMTEXT ?????Reason for Failure to Qualify: FORMTEXT ?????If more space is needed, provide the information on your company’s letterhead with reference to the project name and number, and attach it to this Questionnaire.Unsettled Warranties or ClaimsProvide the following information if Proposer has unsettled/pending claims, demands or notices of default issued by the University of California for University projects:UC Campus Name: FORMTEXT ?????Facility’s Contact Person: FORMTEXT ?????Project Name: FORMTEXT ?????Project Number: FORMTEXT ?????Recorded Date of Claim/Notice: FORMTEXT ?????Type of Warranty: FORMTEXT ?????Basis of Claim: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Status of Unsettled Warranty: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? If more space is needed, provide the information on your company’s letterhead with reference to the project name and number and attach it to this Questionnaire. If additional projects need to be included, copy the table above to include the appropriate information.If the Proposer or Joint Venture partner does not have any unsettled/pending claims, demands or notices of default, please indicate “None” in the space provided: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????[THIS SPACE LEFT INTENTIONALLY BLANK]CONSTRUCTION EXPERIENCEProposer must complete the following information entirely to be considered further.Years of ExperienceDoes your company have at least ten years of experience as a Contractor? Yes FORMCHECKBOX No FORMCHECKBOX Project CompletionHas your company failed to complete a Contract or been removed from a project within the past ten years? Yes FORMCHECKBOX No FORMCHECKBOX If yes, give details including dates: FORMTEXT ????? If more space is needed, provide the information on your company’s letterhead with reference to the project name and number, and attach it to this QuestionnaireLiquidated DamagesHas Proposer been assessed liquidated damages for failing to complete a contract within the time specified in the contract documents within the past ten years? Yes FORMCHECKBOX No FORMCHECKBOX If yes, give details including dates: FORMTEXT ?????If more space is needed, provide the information on your company’s letterhead with reference to the project name and number, and attach it to this QuestionnaireSupplemental Company Information Safety Program Does your company have a written Injury and Illness Prevention Program (IIPP) that complies with California Code of Regulations, Title 8 Sections 1509 and 3203? Yes FORMCHECKBOX No FORMCHECKBOX Does your company have personnel permanently assigned to safety? Yes FORMCHECKBOX No FORMCHECKBOX If yes, state the names of all personnel who are assigned and list their specific duties:Name: FORMTEXT ?????Title: FORMTEXT ?????Specific Duties: FORMTEXT ?????Name: FORMTEXT ?????Title: FORMTEXT ?????Specific Duties: FORMTEXT ?????Comparable Project ExperienceOnly information, experience and Work performed by the Proposers’ office that will bid, manage, coordinate design, construct, and staff the project will be considered for prequalification unless otherwise indicated below. (May include an affiliated office in the same region that shares staff resources.)Submit detailed project documentation including photos that addresses the criteria below for only three (3) projects not less than $600 million in construction cost performed during the past ten (10) years. This documentation shall demonstrate the Proposer’s ability to successfully complete the project with respect to project size, cost, use, complexity, etc. Projects must be at least 50% complete with construction phase to be considered for review. In addition to providing detailed project documentation, each project must be submitted on the form below in this section AND must address the criteria summarized below, to be considered a comparable project: Each project must be a Hospital, Healthcare facility, or highly technical facility of similar scope, cost, size and complexity.One project must be an OSHPD Level 1 Facility. At least two projects must be delivered as a Design-Build contract, or with a GMP Construction Contract having provided Preconstruction Services.One project must have been executed in a collaborative environment such as a “Big Room” co-located project organization structure. Identify all phases for which project was located in Big Room.rOne project must have been delivered with Lean Project Tools. Be specific as to which lean tools were utilized, during design and/or construction phases, on each project.One project must have used Target Value Design and model based estimating.One project must have used pull planning scheduling and resource loaded work plan scheduling. Identify projects where pull plan scheduling was incorporated into the design and construction phases.One project must have been in a congested urban site with adjacencies to existing, operating and occupied facilities.Projects completed prior to January of 2010 will not be considered.For each project please provide owner performance reference. Include owner contact information (name, title, email, phone). Proposed Design-Build Team Members / Key PersonnelAttach a description of your organization and an organizational chart proposed for this project, including but not limited to Proposed Team’s staff, as follows:Project ExecutiveCommissioning CoordinatorProject Manager(s)Lead Project EngineerSuperintendent(s)BIM CoordinatorMEP ManagerSchedulerPre-construction Manager / Cost Estimator(s)OthersFirm must commit Key Personnel for the duration of the project, with all work being done at the Project Big Room (co-location site). Key Personnel include Project Executive, Pre-Construction Manager / Cost Estimator, Superintendent and Project Manager. Provide a resume of each of the Key Personnel for the proposed project team and identified in the organization chart. The resumes of each Key Personnel should address their respective experience with the following:Full name, position in the firm, years with the firm and current location (if a multi-office firm). If less than five years with the firm, provide the name of previous firm.Project role and responsibilities.Education - list all degrees, including institution and year received.Relevant project experience working on similar scope, size and complexity healthcare buildings or hospitals in California, and any other relevant project experiences. Include project name, owner and general contractor, project role and years involved, project description, size (in GSF and construction cost), project delivery method and current status. If the project listed is performed with previous employer, please list the firm’s name.Identify if individual worked on the 3 submitted comparable projects.Relevant project experience with Design-Build delivery method and fast track design packages. Relevant project experience with cost plus GMP accounting method.Relevant project experiences with Integrated Project Delivery (IPD), target value design (TVD), Lean project tools, and with ‘Big Room’. Include project name, owner and general contractor, project role and years involved, project description, size (in GSF and construction cost), project delivery method and current status. If the project listed is performed with previous employer, please list the firm’s name.Relevant project experience with a congested urban site and adjacencies to existing, operating and occupied facilities.Relevant project experience with BIM and it’s integration into a facilities management Lifecycle plan, if applicable. Relevant project experience with model-based estimating & resource loading (i.e. Autodesk Revit, Vico Office Suite, etc.), if applicable to role.EVALUATION SCORINGOnly Proposers who meet all of the minimum requirements listed above will be evaluated for prequalification. Prequalification Scoring Criteria A Maximum of 1000 points is possible. Five or more proposers with the highest scores in Level 1 Prequalification will be invited to participate in Level 2 Interviews. Comparable Project Experience maximum points possible 450 Key Personnelmaximum points possible 550 Please fill in all spaces. Separate sheets must be prepared for each project submitted.[THIS SPACE LEFT INTENTIONALLY BLANK]COMPARABLE PROJECT EXPERIENCE – DESIGN-BUILDERCOMPLETE AND SUBMIT THE FOLLOWING PROJECT DATA SHEET FOR THE EACH OF THE THREE COMPARABLE PROJECTS SUBMITTED AS EVIDENCE OF THE GENERAL CONTRACTOR’S EXPERIENCE. SUBMIT NO MORE THAN THREE. Verify all contacts prior to submittal.Do not leave any spaces blank. Responses such as “N/A” are not acceptable. If not applicable, state “Not Applicable” and explain why. If none, state “NONE.”Required Criteria:Project Name: FORMTEXT ?????Project or Contract Number: FORMTEXT ?????Project Location: FORMTEXT ????? FORMTEXT ?????, FORMTEXT ????? FORMTEXT ?????, FORMTEXT ????? FORMTEXT ?????Street AddressCity & StateZip CodeOwner Information:Owner Information: FORMTEXT ?????Contact Person: FORMTEXT ?????Owner’s NameName & TitleAddress: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeTelephone: FORMTEXT ?????Facsimile: FORMTEXT ?????Email: FORMTEXT ?????Contractor Information:Address of Contractor’s Office that Performed the Work: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeContact Person: FORMTEXT ?????Telephone: FORMTEXT ?????Name & TitleFacsimile: FORMTEXT ?????Email: FORMTEXT ?????Name of Contractor’s Project Manager for project: FORMTEXT ?????Name of Contractor’s Superintendent for project: FORMTEXT ?????Architect Information:Design Firm: FORMTEXT ?????Contact Person: FORMTEXT ?????Name & TitleAddress: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeTelephone: FORMTEXT ?????Facsimile: FORMTEXT ?????Email: FORMTEXT ?????Name of Design Firm’s Project Manager for project: FORMTEXT ?????Contract Time:Start Date: FORMTEXT ?????Scheduled Completion Date: FORMTEXT ?????Month/Day/YearMonth/Day/YearActual Completion Date: FORMTEXT ?????Days Extended due to Unexcused Delays: FORMTEXT ?????(must not be prior to January 2010)Month/Day/YearContract Amount:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Base AmountAdjustment Due to Change OrdersFinal Contract Amount (Min $600M required)Scored Elements:1.Each project must be a Hospital, Healthcare facility, or highly technical facility of similar scope, cost, size and complexity. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO2.One project must be an OSHPD Level 1 Facility. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO3.At least two projects must be delivered as a Design-Build contract, or with a GMP Construction Contract having provided Preconstruction Services. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO4.One project must have been executed in a collaborative environment such as a “Big Room” co-located project organization structure. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO5.One project must have been delivered with Integrated Project Delivery Processes and Practices and Lean Project Tools. Indicate if this project meets this criteria blow. FORMCHECKBOX YES FORMCHECKBOX NO6.One project must have used Target Value Design and model based estimating. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO7.One project must have used pull planning scheduling and resource loaded work plan scheduling. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO8.One project must have been in a congested urban site with adjacencies to existing, operating and occupied facilities. Indicate if this project meets this criteria. FORMCHECKBOX YES FORMCHECKBOX NO9.Projects completed prior to January of 2010 will not be considered.10.For each project please provide owner performance reference. Include owner contact information (name, title, email, phone). CLAIMS HISTORYOnly information for the Proposer’s office that will bid, manage, manage the design, construct, and staff the project shall be submittedOwner Against Contractor ClaimProvide the information requested below for the Contractor (Licensee) listed in Item II.HComplete a separate FORM A – OWNER AGAINST CONTRACTOR CLAIM tabulation sheet for all claims: a) in excess of $30,000 for poor workmanship, incomplete performance, defective work, or b) in excess of $30,000 for unexcused delays in completion, asserted by Owner and/or Performance/Payment Bond sureties against the Contractor within the past five (5) years which were resolved with the result that Contractor, its surety or insurer was required to pay to Owner, or was assessed a deduction in the contract price by Owner, an amount exceeding forty percent (40%) of the highest amount claimed. Claims, as used in the preceding sentence, means all claims adjudicated by a final decision of mediation, arbitration or lawsuit or by negotiated settlement with Owner or third party.A signature by the Proposer’s sole proprietor, general partner, or corporate officer is required on Form A. If signed by other than the sole proprietor, a general partner or corporate officer, attach original notarized power of attorney or corporate resolutionContractor Against Owner ClaimProvide the information requested below for the Contractor (Licensee) listed in Item II.plete a separate FORM B – CONTRACTOR AGAINST OWNER CLAIM tabulation sheet for all claims (including false claims) in excess of $30,000 for extra compensation or damages asserted by Contractor against Owners within the past five (5) years, which were resolved with the result that Contractor received less than sixty percent (60%) of the highest amount claimed. Claims, as used in the preceding sentence, includes claims for extra compensation or damages and includes subcontractor claims (“pass through” claims) even if the contractor had no interest in those claims. Claims, as used in the preceding sentence, means all claims adjudicated by a final decision of mediation, arbitration or lawsuit or by negotiated settlement with Owner or third party. Do not include stop notices or causes of action to enforce stop notices.A signature by the Proposer’s sole proprietor, general partner, or corporate officer is required on Form B. If signed by other than the sole proprietor, a general partner or corporate officer, attach original notarized power of attorney or corporate resolution.OWNER AGAINST CONTRACTOR CLAIMT FORM AUse one Form per Lawsuit or Arbitration (Make Copies as Needed)Are there claims that meet the criteria in Section V.A of this statement? If yes, please complete & sign the form below: Yes FORMCHECKBOX No FORMCHECKBOX Case Name and Number including Name and Location of Court or Arbitration Service: FORMTEXT ?????Date Arbitration or Litigation Commenced: FORMTEXT ?????Project Name: FORMTEXT ?????Project or Contract Number: FORMTEXT ?????Project Location: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeName of Owner: FORMTEXT ?????Contact Person: FORMTEXT ?????Telephone: FORMTEXT ?????Name & TitleHighest Amount Sought for All Claims:$ FORMTEXT ?????(Amount in Figures)Amount Recovered:$ FORMTEXT ?????(Amount in Figures)Method of Resolution (Check One):Judgment: FORMCHECKBOX Arbitration Award: FORMCHECKBOX Litigation: FORMCHECKBOX Settled by Contracting Parties without Litigation or Arbitration: FORMCHECKBOX Other: FORMCHECKBOX List: FORMTEXT ?????Date of Claim Resolution: FORMTEXT ?????Basis for Claim: FORMTEXT ?????If the lawsuit or arbitration was resolved for more than forty percent (40%) of the highest amount sought for all claims, state why the lawsuit or arbitration should not be considered a meritorious lawsuit or arbitration filed by an owner against Contractor and/or persons or entities associated with Contractor: My signature below signifies my declaration that the answers provided on this Form A are current, accurate, and complete.Proposer’s Signature:Printed Name & Title FORMTEXT ?????DateIf signed by other than the sole proprietor, a general partner or corporate officer, attach original notarized power of attorney or corporate resolution.OWNER AGAINST CONTRACTOR CLAIM CONTRACTOR AGAINST OWNER CLAIMFORM BUse one Form per Lawsuit or Arbitration (Make Copies as Needed)Are there claims that meet the criteria in Section V.B of this statement? If yes, please complete & sign the form below: Yes FORMCHECKBOX No FORMCHECKBOX Case Name and Number including Name and Location of Court or Arbitration Service: FORMTEXT ?????Date Arbitration or Litigation Commenced: FORMTEXT ?????Project Name: FORMTEXT ?????Project or Contract Number: FORMTEXT ?????Project Location: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeName of Owner: FORMTEXT ?????Contact Person: FORMTEXT ?????Telephone: FORMTEXT ?????Name & TitleHighest Amount Sought for All Claims:$ FORMTEXT ?????(Amount in Figures)Amount Recovered:$ FORMTEXT ?????(Amount in Figures)Method of Resolution (Check One):Judgment: FORMCHECKBOX Arbitration Award: FORMCHECKBOX Litigation: FORMCHECKBOX Settled by Contracting Parties without Litigation or Arbitration: FORMCHECKBOX Other: FORMCHECKBOX List: FORMTEXT ?????Date of Claim Resolution: FORMTEXT ?????Basis for Claim: FORMTEXT ?????If the lawsuit or arbitration was resolved for more than sixty percent (60%) of the highest amount sought for all claims, state why the lawsuit or arbitration should not be considered a meritorious lawsuit or arbitration filed by an owner against Contractor and/or persons or entities associated with Contractor:My signature below signifies my declaration that the answers provided on this Form B are current, accurate, and complete.Proposer’s Signature:Printed Name & Title FORMTEXT ?????DateIf signed by other than the sole proprietor, a general partner or corporate officer, attach original notarized power of attorney or corporate resolution.VI.REQUIRED COMPLETED ATTACHMENTS1.Notarized Statement from Surety stating (reference Section II.M):a. Current available bonding exceeds the project Estimated Construction Cost;b. Total bonding capacity;c. Surety(ies) proposed to be used on the project is an admitted surety insurer as defined in the California Code of Civil Procedure Section 995.120;d. Surety(ies) acknowledge its intent to provide bonding of the Project in the event Contractor is awarded the Project.2.Audited Financial Statements (reference Section II.N).3.Written declaration from your insurance agent/broker/carrier stating that your firm can obtain insurance coverage in the required limits and ratings for the project (reference Section II.O).4.Insurance Certificate (reference Section II.O).5.Letter from Workers’ Compensation carrier evidencing your EMR for the past 5 years (reference Section II.P)6.List of comparable projects. (reference Section III.E).7.Resumes of all proposed Key Personnel (reference Section III.F).8.Signature declaring the answers on Forms A, and B are true and correct (reference Section V).VII.DECLARATIONDECLARATIONI, FORMTEXT ?????hereby declare that I am the FORMTEXT ?????Printed NameTitleof FORMTEXT ?????submitting this Prequalification Questionnaire; that I Company Nameam duly authorized to execute this Questionnaire on behalf of Proposer; and that all information set forth in this Questionnaire and all attachments hereto are, to the best of my knowledge, current, accurate, and complete as of its submission date.I declare, under penalty of perjury, that the foregoing is true and correct and that this declaration was executed at FORMTEXT ?????County of FORMTEXT ?????Location and CityCountyState of FORMTEXT ?????on FORMTEXT ?????.StateDateSignature FORMTEXT ?????Printed NameIf signed by other than the sole proprietor, a general partner, or corporate officer, attach original notarized power of attorney or corporate resolution. ................
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