GENERAL CONTRACTOR
DESIGN BUILDERPREQUALIFICATION QUESTIONNAIREPROJECT NO. 9557280MEDICAL OFFICE BUILDING (MOB) AT THE FOLSOM HEALTH FACILITYDESIGN-BUILD DELIVERYMandatory Prequalification Conference: 10:00 a.m. Tuesday, March 9, 2021Prequalification Questionnaire Due Date: 4:00 p.m. Monday, April 12th, 2021Facilities Design & ConstructionQuestions to FD&C Contracts:4800 2nd Avenue, Suite 3010Hans Ram, Contracts AdministratorSacramento, CA 95817hlram@ucdavis.edu OF CONTENTS TOC \o "1-3" \h \z \u I.GENERAL PAGEREF _Toc63928561 \h 1A.Project Description PAGEREF _Toc63928562 \h 1B.Project Timing PAGEREF _Toc63928563 \h 1C.Project Anticipated Construction Cost PAGEREF _Toc63928564 \h 2D.Land Use and Permitting PAGEREF _Toc63928565 \h 2E.Utilities PAGEREF _Toc63928566 \h 2F.Project Delivery PAGEREF _Toc63928567 \h 3G.Interested Parties PAGEREF _Toc63928568 \h 3J.Joint Ventures PAGEREF _Toc63928569 \h 3K.University Controlled Insurance Program (UCIP) PAGEREF _Toc63928570 \h 3II.Prequalification Process – Design Build Delivery PAGEREF _Toc63928571 \h 4L.Prequalification Questionnaire Availability PAGEREF _Toc63928572 \h 4M.Questions PAGEREF _Toc63928573 \h 4N.Mandatory Prequalification Conference PAGEREF _Toc63928574 \h 4O.Submittal Procedures and Deadline PAGEREF _Toc63928575 \h 4P.Rating and Evaluation Procedures PAGEREF _Toc63928576 \h 5Q.Content of Prequalification Submission PAGEREF _Toc63928577 \h 5I.PREQUALIFICATION QUESTIONNAIRE – REQUIRED ELEMENTS PAGEREF _Toc63928578 \h 9A.Proposer Company Name and Address PAGEREF _Toc63928579 \h 9B.Contact Information PAGEREF _Toc63928580 \h 9C.Entity Submitting this Prequalification Questionnaire PAGEREF _Toc63928581 \h 9D.Type of Business Organization PAGEREF _Toc63928582 \h 9E.Year Company was Established PAGEREF _Toc63928583 \h 10F.Parent Company Information PAGEREF _Toc63928584 \h 10G.List All Former Company Names PAGEREF _Toc63928585 \h 10H.License and Registration with California DIR PAGEREF _Toc63928586 \h 10I.Design Firm (Architect) PAGEREF _Toc63928587 \h 11J.Debarment PAGEREF _Toc63928588 \h 12K.Labor Code Violations PAGEREF _Toc63928589 \h 12L.Surety PAGEREF _Toc63928590 \h 12M.Financial Capability PAGEREF _Toc63928591 \h 12N.Financial Data PAGEREF _Toc63928592 \h 12O.Insurance PAGEREF _Toc63928593 \h 13P.Experience Modification Rate PAGEREF _Toc63928594 \h 14Q.Qualification History PAGEREF _Toc63928595 \h 15R.Unsettled Warranties or Claims PAGEREF _Toc63928596 \h 15II.CONSTRUCTION EXPERIENCE PAGEREF _Toc63928597 \h 16A.Years of Experience PAGEREF _Toc63928598 \h 16B.Project Completion PAGEREF _Toc63928599 \h 16C.Liquidated Damages PAGEREF _Toc63928600 \h 16D.Supplemental Company Information PAGEREF _Toc63928601 \h PARABLE PROJECT EXPERIENCE PAGEREF _Toc63928602 \h 17IV.PROPOSED KEY PERSONNEL PAGEREF _Toc63928603 \h 20V.EVALUATION SCORING PAGEREF _Toc63928604 \h 20A.Scoring Criteria PAGEREF _Toc63928605 \h parable Project Experience PAGEREF _Toc63928606 \h 20C.Proposed Key Personnel PAGEREF _Toc63928607 \h 21VI.CLAIMS HISTORY PAGEREF _Toc63928608 \h 21A.Owner Against Contractor Claim PAGEREF _Toc63928609 \h 21B.Contractor Against Owner Claim PAGEREF _Toc63928610 \h 21C.Owner Against Design Firm Claim PAGEREF _Toc63928611 \h 21VII.DECLARATION PAGEREF _Toc63928612 \h 25GENERALProject Description The Project will be constructed on a roughly 36-acre parcel located adjacent to East Bidwell Street and one block north of Alder Creek Parkway in the Folsom Area Specific Plan, known as Folsom Ranch (“Site”).The Project will consist of the following:Medical Office Building (“MOB”) and associated Site Infrastructure, Hardscapes, Landscapes, and ParkingBased upon an initial internal assessment of space needs, the University has identified certain uses and programmatic requirements for its own account, estimated at ~60,000 GSF for the MOB. The MOB is assumed to be a two or three-story building at approximately 20,000-30,000 GSF for each floor and will house clinical space that will relocate from existing leased space and possibly an additional portion of OSHPD-3 space. A preliminary space and functional program for the MOB will been completed by the University and will be included with the Request for Proposals issued to the successful qualified proposers. The project will meet UC Sustainable Practices Policy (UCSPP) and will be a minimum of LEED Silver. The project will be required to meet UC Sustainable Practices Policy (UCSPP), as well as the University’s Carbon Neutrality Initiative, which commits the University to emitting net zero greenhouse gases from its buildings and vehicle fleet by 2025. Project design should minimize energy and water consumption, waste, and wastewater production; incorporate sustainable design principles into lifecycle capital investment decisions; and green landscape infrastructure to maximize the resilience of structures in the face of changing environmental conditions including seismic risk and climate change. Additional details can be found at the following website: . Additional master plan sustainability goals will be provided as part of the RFP process.Project TimingThe Project will proceed in four phases: Phase 1:Design Development Documents Phase 2:Construction Documents Phase 3:Construction Phase 4:Post Construction Warranty The Project will commence with a Notice to Proceed (NTP) for Phase 1 immediately upon selection, award, and execution of the Contract. The University Milestone Schedule indicates 18 months for the completion of Phases 1 and 2 including permitting, between 18-24 months for Phase 3 (concurrent phases 1-3 envisioned to expedite delivery), and 12 months for Phase 4.Estimated Project Award Date: October 2021Estimated Project Duration: 36 Months (to Owner move-in)Anticipated Selection Process ScheduleLEVEL 1: SchedulePrequalification Documents Available Tuesday – February 23, 2021Last day to Request Zoom Link to ConferenceMonday – March 8, 2021 at 12:00 p.m.Mandatory Prequalification ConferenceTuesday – March 9, 2021 at 10:00 a.m.Last day to submit questions (RFIs) Thursday – March 25, 2021Last day Clarifications Issued (if required)Friday – April 2, 2021Last day to request Electronic Upload LinkThursday – April 8, 2021Prequalification Documents Due Monday – April 12, 2021 at 4:00 p.m.LEVEL 2:ScheduleShortlist notified Monday – April 26, 2021Interviews Day 1Tuesday – May 11, 2021 andInterviews Day 2Wednesday – May 12, 2021Shortlist NotifiedFriday – May 14, 2021LEVEL 3: ScheduleRFP issued to shortlistMonday – June 7, 2021Level 3 Mandatory MeetingThursday – June 10, 2021Confidential Meeting #1 Week of June 28, 2021Confidential Meeting #2Week of July 19, 2021Confidential Meeting #3Week of August 9, 2021Last day to submit questions (RFIs)Friday – August 20, 2021Last day clarifications issued (if required)Friday – August 27, 2021RFP Submittals Due Monday – September 6, 2021 at 4:00 p.m.Final InterviewWednesday – September 22, 2021Notice of Intent to Award Friday – October 1, 2021AwardThursday – October 7, 2021The University reserves the right to change any and/or all of the dates stated above. Any changes to the schedule for the Design Builder selection process will be issued by addenda.Project Anticipated Construction Cost The anticipated construction cost (inclusive of preconstruction, design and construction cost) is as follows:MOB Anticipated Construction Cost: $43,000,000 At the time of the Request for Proposal (RFP) the Project’s Maximum Allowable Cost (MAC) will be established. The MAC is the maximum amount the University will spend on the Project, inclusive of preconstruction, design and construction cost. The planning and design of the Project must meet the MAC of the project and the Design Builder must follow the Target Value Design and/or the model-based estimating approach. Land Use and PermittingIn general, the University is not subject to local land use regulations and functions as the permitting agency, acting in its sovereign and autonomous government capacity under Article IX of the California State Constitution, as building official with full power and authority to authorize, approve, permit and inspect the design, alteration, improvement, and construction of buildings and structures, including related to design review, building permit issuance, construction inspections, permit sign-off, final inspections, and issuance of certificate of occupancy. However, the intent of the Project is to comply as closely as possible with local land use ordinances and guidelines, and to coordinate planning and review with the City of Folsom to ensure engagement with the City and keep the surrounding community informed.Issuance of building permits will be dependent upon submittals of appropriate design submittals. Certain approvals, inspections, and permits may be coordinated or informed by the City of Folsom, including but not limited to fire department, waste management, water, sewer, and stormwater services. The Project is expected to be exempt from most local development impact fees. UtilitiesDevelopment of Project Sites should assume connection and service to public utilities; the Design-Builder shall be responsible for fees, approvals, inspections, permits and verification of utility capacity and development needs. Coordination with the utility providers to site is essential as is compliance with University of California policies including sustainability and carbon neutrality.Project DeliveryThe selected Design-Builder will provide 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. 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, permitting, inspections, site preparation, site utilities, utility connections, hardscape and landscape, and surface improvements. The Project will require the Design-Builder, including the General Contractor, all design consultants, design-build subcontractors and other subcontractors working on the Project to be co-located (at least 2 days a week) at minimum either in-person or virtually, for the duration of their work on the project.Interested PartiesConsultants to the University who are participants or advisors to the University with respect to this project, including the preparation of criteria documents, are exempt from participating as a Design Builder team member or as a Subconsultant, of any Tier, to the Design Builder. Therefore, for this project, the following firms are not eligible to participate in this project:JacobsBiomimicry 3.8Mackay & Somps Civil EngineersTaylor DesignProgressive Design Build Consultants, LLCLeap StepJoint 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.N Rating and Evaluation Procedures. Section II.L Surety, shall be submitted on one of the two applicants’ forms completely documenting the stated requirements by a qualified Surety. Requests of Design-Build 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 in the RFP.Prequalification Process – Design-Build DeliveryThe purpose of this Prequalification process is to establish a shortlist of highly qualified Design-Builders for the project. The Design-Builder Prequalification is a two-step process: Level 1 – Submittal of Prequalification documents, and Level 2 – the Interviews. This process will result in the selection of a prequalified shortlist of three teams receiving the Request for Proposals (RFP) and commencement of Level 3 – Submittal of Technical and Cost proposal. 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 proceed to Level 2, the Interview, and will be notified via email. 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): Selected prequalified proposers receive the RFP and will submit cost and technical proposals at the conclusion of the competition stage. The cost submittal that is part of the RFP will consist of a percentage of fee for the construction work, and rates for professional services during design and preconstruction, including rates for all General Contractor Personnel for all five phases of work. A limited design concept, 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 (Best Value). The prequalified proposer with the lowest price per point will be the apparent Best Value for the Project. 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 starting Tuesday, February 23, 2021, and can be downloaded directly from our website at: questions and issues regarding the Prequalification Process, requirements, criteria, and/or information, must be submitted electronically by emailing Hans Ram, FD&C Contracts Administrator, at hlram@ucdavis.edu. All questions must be submitted no later than the due date indicated in the Anticipated Selection Process Schedule. Questions received after the due date will not be considered. Mandatory Prequalification ConferenceProposers must attend a MANDATORY Prequalification Conference, which will be held online, at 10:00 a.m. on Tuesday, March 9, 2021. A Zoom meeting link will be distributed to Proposers who request it by 12:00 p.m. on Monday, March 8, 2021. Only Proposers who participate in the Prequalification Conference, in its entirety, will be allowed to propose on the project. Participants must join the virtual meeting before 10:00 a.m.; the virtual meeting room will be open no later than 9:45 a.m. Participants arriving later than 10:00 a.m. will not be allowed to submit proposals as a Design Builder on the project. Attendance will be confirmed by roll call; please designate one person from each firm who will confirm attendance. 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. Each copy of the submittal must be complete and fully responsive to the requirements of the Prequalification Questionnaire.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. Completed Prequalification Questionnaires must be submitted electronically no later than Monday – April 12, 2021 at 4:00 p.m. to the link to be provided by UC Davis Health. Prequalification documents will not be accepted after the due date and time. No supplemental data or additional project information will be accepted after due date and time unless specifically requested by the University. No hard copies will be accepted.Proposers interested in prequalifying to propose on this project must email Hans Ram, FD&C Contracts Administrator, at hlram@ucdavis.edu by Thursday – April 8, 2021 at 4:00 p.m. to be provided a link to upload their Qualifications package.Upload one (1) electronic copy (pdf format) of the Prequalification Questionnaire Documents to the link provided by the University. Submittals must be received no later than 4:00 p.m., MONDAY APRIL 12, 2021. Rating and Evaluation ProceduresTo be considered for prequalification, a prospective Proposer must have:CONSTRUCTION EXPERIENCE: Have sufficient project experience for the Design Builder as referenced in Section II. The projects submitted will receive points based on the extent to which they meet the listed criteria, per Section III.KEY PERSONNEL: Demonstrate adequate experience for Design Builder Key Personnel as referenced in Section IV (information submitted will receive points based on experience per Section V).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 Project anticipated construction costs.)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 (2017,2018,2019) equal to or greater than $25,000,000. declaration: Certify that all requested information is current, accurate, and complete.To be considered for prequalification the prospective Design-Builders, including any proposed joint venture partners, must not have:EXPERIENCE MODIFIER RATE: An average Experience Modifier Rate (EMR: Workers’ Comp) injury rating greater than 1.0 for the past five (5) 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 Sections VI.A & VI.C, and have not filed a claim against an Owner that meets the parameters specified in Section VI.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.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.Proposers selected for interviews will be notified via email, and will specify the date, time, and location of their interviews and outline the interview process. The University reserves the right to re-open the Design Builder prequalification process if the University determines that there are insufficient prequalified Design Builders to support the Proposal process.Content of Prequalification SubmissionAt a minimum, all Prequalification Submissions must include:1.Cover Letter (1 page)Provide a cover letter that summarizes and demonstrates your understanding of the Project and the focus on patient experience, as well as the ability of your proposed team to successfully deliver a completed project which supports UC Davis Health’s goals.2. Prequalification Questionnaire & Financial Stability – Item I3. Construction Experience – Questionnaire Item II parable Project Experience – Questionnaire Item III5. Proposed Key Personnel – Questionnaire Item IV6.Record of Claims, Legal Actions and Terminations – Questionnaire Item VI7.Declaration – Questionnaire Item VII8. Required Completed AttachmentsNotarized Statement from Surety stating (reference Section I.M – Financial Capacity):Current available bonding exceeds the project anticipated construction cost;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) acknowledge its intent to provide bonding of the Project in the event Design Builder is awarded the Project.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 I.O – Insurance).Insurance Certificate (reference Section I.O – Insurance).Letter from Workers’ Compensation carrier evidencing your EMR for the past 5 years (reference Section I.P – Experience Modification Rate)Signature declaring the answers on Forms A, B, and C are true and correct (reference Section VI – Claims History). [THIS SPACE LEFT INTENTIONALLY BLANK]PREQUALIFICATION QUESTIONNAIREforMedical Office Building (MOB) at the Folsom Health FacilityProject No.: 9557280FACILITIES DESIGN AND CONSTRUCTIONUC DAVIS HEALTHSACRAMENTO, CALIFORNIAEach prospective Proposer must have the appropriate contractor’s/designer’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 proposal will be 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 executed.in 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 ?????(Telephone Number)(Email Address)(Signature) FORMTEXT ?????(Typed Name and Title)Each prospective Proposer must answer all 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 with the University 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 hearing or a written response from University. The decision of the University is final and not appealable within the University of California.Design Firm (Architect) Contact information:Firm Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TelephoneFacsimileStreet Address: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeContact Person: FORMTEXT ????? FORMTEXT ?????Name, TitleTelephone Provide the name of the Architect of Record to be used on the Project: FORMTEXT ????? FORMTEXT ?????Name, TitleCurrent License NumberThe 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 with a design firm as a subcontractor or it may be a joint venture between a construction company and a design firm. In such cases, each member of the Proposer shall submit project experience as required below and such design firms shall comply with the laws of the State of California, applicable to such firms. However, 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.[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 qualified.note: if “yes” is answered to any of the yes/no questions in this section, you have not met the minimum qualifications for further consideration for this project.Proposer Company Name and AddressCompany Name: FORMTEXT ????? FORMTEXT ?????TelephoneStreet 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 Questionnaire.Year 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 LACK the required California State Contractors license?Yes FORMCHECKBOX No FORMCHECKBOX Is your firm NOT 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 license 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 (10) years? FORMCHECKBOX YES FORMCHECKBOX NODesign Firm (Architect)Firm Name: FORMTEXT ????? FORMTEXT ?????TelephoneStreet Address: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeContact Person: FORMTEXT ????? FORMTEXT ?????Name, TitleTelephone Provide the name of the Architect of Record to be used on the Project: FORMTEXT ????? FORMTEXT ?????Name, TitleCurrent License NumberDebarmentHas your company entity (or any member of the entity if a joint venture or partnership) been disqualified or barred from doing business with a public agency (e.g., federal, state, county, city, University of California System, California State University System, etc.) within the last ten (10) years? FORMCHECKBOX YES FORMCHECKBOX NOLabor Code ViolationsHas your company, during the past ten (10) 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? FORMCHECKBOX YES FORMCHECKBOX NOSuretyList below all Surety companies used by your company within the past five (5) 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 NameTelephoneStreet Address: 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 NameTelephoneStreet Address: 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 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 Project’s anticipated ; (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 DataUpon request provide your company’s Total Revenue, Net Income, Current Assets, Current Liabilities, Total Debt, and Total Net Worth for the past three (3) fiscal years. Also, 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 Ending2017$ FORMTEXT ?????Year Ending2018$ FORMTEXT ?????Year Ending2019$ FORMTEXT ?????3 year Average: $__________________________Net Income (past 3 fiscal years):Year Ending2017$ FORMTEXT ?????Year Ending2018$ FORMTEXT ?????Year Ending2019$ FORMTEXT ?????Current Assets (past 3 fiscal years):Year Ending2017$ FORMTEXT ?????Year Ending2018$ FORMTEXT ?????Year Ending2019$ FORMTEXT ?????Current Liabilities (past 3 fiscal years):Year Ending2017$ FORMTEXT ?????Year Ending2018$ FORMTEXT ?????Year Ending2019$ FORMTEXT ?????Total Debt (past 3 fiscal years):Year Ending2017$ FORMTEXT ?????Year Ending2018$ FORMTEXT ?????Year Ending2019$ FORMTEXT ?????Total Net Worth (past 3 fiscal years):Year Ending2017$ FORMTEXT ?????Year Ending2018$ FORMTEXT ?????Year Ending2019$ FORMTEXT ?????7. Total Bonding Capacity$ FORMTEXT ????? 8. Total Available Bonding Capacity$ FORMTEXT ?????Does your firm have a three-year (3) average revenue less than $25,000,000? YES FORMCHECKBOX NO FORMCHECKBOX Financial Statement(s): Upon request provide copies of audited financial 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, Contractor’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:$2,000,000Architect’s Professional (Errors and Omissions) Liability – Limits of LiabilityMinimum RequirementsEach Occurrence & Aggregate:$5,000,000Workers’ 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:$10,000,0001.Will your firm be UNABLE to obtain the insurance in the required limits and ratings from companies that meet the criteria stated above? YES FORMCHECKBOX NO FORMCHECKBOX 2.If “no,” 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 five years and the five-year average:2015: FORMTEXT ?????2016: FORMTEXT ?????2017: FORMTEXT ?????2018: FORMTEXT ?????2019: FORMTEXT ?????Average:Submit a letter from your Workers’ Compensation carrier showing the Experience Modification rate for the past five years.Has your Worker’s Compensation Experience Modification Rate average risen above 1.0 over the last five (5) years?YES FORMCHECKBOX NO FORMCHECKBOX Qualification HistoryHas the Proposer failed to qualify to perform work for University of California?YES FORMCHECKBOX NO FORMCHECKBOX Unsettled Warranties or ClaimsDoes the Proposer have unsettled/pending claims, demands or notices of default issued by the University of California for University projects?YES FORMCHECKBOX NO FORMCHECKBOX note: if “yes” is answered to any of the yes/no questions in this section, you have not met the minimum qualifications for further consideration for this project.[THIS SPACE LEFT INTENTIONALLY BLANK]CONSTRUCTION EXPERIENCEProposer must complete the following information entirely to be considered further.Years of ExperienceDoes Proposer have at least ten (10) years of experience as a General Contractor? Yes FORMCHECKBOX No FORMCHECKBOX Does Proposer have at least ten (10) years of experience as a Design Firm? Yes FORMCHECKBOX No FORMCHECKBOX Project CompletionHas Proposer failed to complete a Contract or been removed for cause from a project within the past ten (10) years? Yes FORMCHECKBOX No FORMCHECKBOX If yes, give details including dates: FORMTEXT ????? If more space is needed, provide the information on company letterhead with reference to the project name and number, and attach it to this QuestionnaireLiquidated Damages Has 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 and damage values: FORMTEXT ?????If more space is needed, provide the information on company letterhead with reference to the project name and number, and attach it to this QuestionnaireSupplemental Company Information Contractor 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 COMPARABLE PROJECT EXPERIENCESubmit detailed project documentation including images (1 page) for only five (5) projects not less than $10 million in construction cost performed during the past ten (10) years (completed after 2010). Each project must be at least 50% complete within the construction phase. A minimum of 2 projects must be submitted by the Contractor and a minimum of 2 projects must be submitted by the Design Firm.The detailed project documentation shall demonstrate the Design-Builder’s ability to successfully complete the Project and will be evaluated based on the following criteria:Similarity to Project in scope, size, complexity, and location. Project exhibits outstanding design quality and sustainable design. Project delivered by one or multiple proposed Key Personnel.Project utilized LEAN delivery methodologies.Project was Design-Build or similar delivery method.In addition to providing detailed project documentation, each project must be submitted on the form below in this section.Separate sheets must be prepared for each project submitted.[THIS SPACE LEFT INTENTIONALLY BLANK]COMPARABLE PROJECT EXPERIENCE DATA SHEET COMPLETE AND SUBMIT THE FOLLOWING PROJECT DATA SHEET FOR EACH OF THE FIVE COMPARABLE PROJECTS SUBMITTED AS EVIDENCE OF THE DESIGN-BUILDER’S EXPERIENCE. SUBMIT NO MORE THAN FIVE. 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 ????? 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 & TitleEmail: 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 ?????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 December 2010)Month/Day/YearContract Amount:$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Base AmountAdjustment Due to Change OrdersFinal Contract AmountMinimum Project Requirements:1.Project Submitted by: FORMCHECKBOX Contractor FORMCHECKBOX Design Firm FORMCHECKBOX Contractor and Design Firm2.Project submitted at least $10,000,000 construction value? FORMCHECKBOX YES FORMCHECKBOX NO3.Project is at least 50% complete with construction? FORMCHECKBOX YES FORMCHECKBOX NO4.Projects completed prior to December of 2010 will not be considered.5.For each project please provide reliable owner contact information. [THIS SPACE LEFT INTENTIONALLY BLANK]PROPOSED KEY PERSONNELAttach a description of your organization and an organizational chart proposed for this project, that includes the Key Personnel listed in the table below. It is understood that the full project team will include additional staff, consultants and subcontractors that do not need to be listed at this time for determination of prequalification. Please do not include information on any team members not specifically requested. Provide staff availability information for the Key Personnel in matrix form. At a minimum include project role and duration of individual assignments (by percent of time allocated per project phase). Note: Key Personnel must be committed for the duration of the project.CONTRACTORDESIGN FIRMENGINEERSProject Executive (10 pts) Architect of Record (10 pts)Structural Engineer of Record (10 pts)Project Manager (13 pts)Project Manager (13 pts)Mechanical Engineer of Record (10 pts)Pre-Construction Manager (13 pts)Designer (13 pts)Plumbing Engineer of Record (10 pts)Superintendent (13 pts)Project Architect (13 pts)Electrical Engineer of Record (10 pts)Cost Estimator (13 pts)Interior Designer (13 pts)Civil Engineer of Record (10 pts)Medical Equipment Planner (13 pts)Landscape Architect (13 pts)Provide a 2-page max resume for the Key Personnel. At a minimum, include 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.Certifications – list all certifications, including LEED, DBIA, etc.Relevant project experience working on buildings of similar scope, size, complexity, and delivery model. Include:Project name and ownerProject description (including distinguishing/innovative features, technical achievements, or project awards)Size (construction cost), project delivery method, and current status (completion date if applicable).If the project listed is performed with previous employer, please list the firm’s name.Identify if individual worked on any of the five (5) submitted comparable projects.EVALUATION SCORINGScoring Criteria Only Design Builders who meet all of the minimum requirements listed herein will be evaluated for prequalification. A maximum of 500 points is possible. Five Design Builders with the highest scores on this Prequalification Questionnaire will be invited to participate in Level 2 Interviews. Required Financial, Insurance, & Claims History Datapass/fail Required Current Licensespass/fail Owner Reference Provided for Each Projectpass/fail Comparable Project Experience 300 points Proposed Key Personnel200 points Total Possible:500 pointsComparable Project ExperienceOnly five (5) comparable projects may be submitted with a collective maximum of 300 points. The projects will be scored based on the following criteria with points awarded as noted:(25 points possible per project) Similarity to Project in scope, size, complexity, and location.(15 points possible per project) Project exhibits outstanding design quality, including sustainable design. (10 points possible per project) Project delivered by one or multiple proposed Key Personnel.(5 points possible per project) Project utilized LEAN delivery methodologies.(5 points possible per project) Project was Design-Build or similar delivery method.Proposed Key PersonnelResumes of the Key Personnel may be submitted with a collective maximum of 200 points. Points will be awarded per Key Personnel as indicated on the Key Personnel Table above. Key Personnel resumes will be evaluated based on the following factors:Proposed Key Personnel have experience on projects similar to MOB in scope, size, complexity and attributes.Proposed Key Personnel have delivered projects of outstanding design quality, including sustainable design (list distinguishing accomplishments such as innovative features, technically demanding successes, and/or awards received for projects)CLAIMS HISTORYOnly information for the Proposer’s office that will bid, manage the design, construct, and staff the project shall be submittedOwner Against Contractor ClaimProvide the information requested below for the Contractor (Licensee) listed in Section II.plete a separate FORM A – OWNER AGAINST CONTRACTOR CLAIM tabulation sheet for all claims: a) in excess of $100,000 for poor workmanship, incomplete performance, defective work, or b) in excess of $100,000 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 Section II.plete a separate FORM B – CONTRACTOR AGAINST OWNER CLAIM tabulation sheet for all claims (including false claims) in excess of $100,000 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 Design Firm ClaimProvide the information requested below for the Design Firm (Licensee) listed in Section II.plete a separate FORM C - OWNER AGAINST DESIGN FIRM CLAIM tabulation sheet for all claims in excess of $100,000 for either excessive Change Orders, lack of coordination or design errors and omissions asserted by Owner over the past five (5) years which were resolved with the result that the Architect or its insurer was required to pay to Owner, or was assessed a deduction in fee by Owner, an amount exceeding forty percent (40%) of the highest amount claimed.A signature by the Proposer’s sole proprietor, general partner, or corporate officer is required on Form C. If signed by other than the sole proprietor, a general partner or corporate officer, attach original notarized power of attorney or corporate resolution.OWNER AGAINST CONTRACTOR CLAIMT FORM AUse one Form per Lawsuit or Arbitration (Make Copies as Needed)Are there claims that meet the criteria in Section V.A of this statement? If yes, please complete & sign the form below: Yes FORMCHECKBOX No FORMCHECKBOX Case Name and Number including Name and Location of Court or Arbitration Service: FORMTEXT ?????Date Arbitration or Litigation Commenced: FORMTEXT ?????Project Name: FORMTEXT ?????Project or Contract Number: FORMTEXT ?????Project Location: FORMTEXT ?????, FORMTEXT ?????, FORMTEXT ?????Street AddressCity & StateZip CodeName of Owner: FORMTEXT ?????Contact Person: FORMTEXT ?????Telephone: FORMTEXT ?????Name & TitleHighest Amount Sought for All Claims:$ 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.OWNER AGAINST DESIGN FIRM CLAIMT FORM CUse one Form per Lawsuit or Arbitration (Make Copies as Needed)Are there claims that meet the criteria in Section V.C 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 Design Firm and/or persons or entities associated with Design Firm: My signature below signifies my declaration that the answers provided on this Form C are current, accurate, and complete.Design Firm’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.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.[END] ................
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