Fillable UPCCA Contractor Questionnaire 2019 - UPCCA_Contractor_Questionnaire_2018

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UPCCA Contractor Questionnaire 2019 - UPCCA_Contractor_Questionnaire_2018

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Page1of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

1499N.STATEST,SANJACINTO,CA92583

UPCCAAPre‐QualificationQuestionnairefor2019CalendarYear

CONTRACTORINFORMATION

FirmName:__________________________________________ ____________________________

(Asitappearsonstatelicense)

DBA: _________________________________ _________________________________________

Address:__________________________________________________________________________

_________________________________ _________________________________________

ContactPerson(s):_______________________________________________ __________________

TelephoneNo: __________________________ Facsimile:_________________________

EmailAddress: __________________________ _________________________________________

CheckOne:

Corporation Partnership SoleProprietorship

YearsinbusinessinCaliforniaasa

Contractorunderyourpresentbusinessnam e:______years

IfFirmisaSoleProprietororPartnership,pleaselistOwner(s)ofFirm:

_________________________________ ________________________________________________

PleaselistanyformerBusinessNames:

_________________________________ ________________________________________________

DIRREGISTRATIONNUMBER EXPIRATIONDATE

________________________ _________________

ContractorsandsubcontractorsmustbecurrentlyregisteredwiththeDIRandmeettherequirements

ofLaborCodeSection1725.5priortobiddingorperforminganyDistrictPublicWorksprojects.

ForregistrationandmoreinformationpleasevisittheStateofCalifornia’sDepartmentofIndustrial

Relationswebpageathttps://www.dir.ca.gov/

Page2of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

CONTRACTORINFORMATION–Cont’d

CaliforniaLicenses:

CLASS/CERT DESCRIPTION LICENSE# EXPIRATIONDATE

___________ ___________________________ __________ _____________

PrimaryTypeofWorkInterest: _____________________________________________________

(ListonlyOne,Example:Mechanical,Electrical,Plumbing,GeneralEngineering,GeneralBuilding) 

SecondaryTypeofWorkInterest:___________________________________________________

BondingCapacity(perContract):$____________________________

NameofBondingCompany: _________________________

 Telephon

e:_________________

Specifyifyourbusinessis:

1. DisabledVeteranBusinessEnterprise(DVBE)

Yes No

Ifyes,pleasesubmitacopyofcertificationwiththisapplication

2. SmallBusinessEnterprise(SBE)

Yes No

Ifyes,pleasesubmitacopyofcertificationwithth

isapplication

3. WomenOwnedBusinessEnterprise(WBE)

Yes No

4. MinorityOwnedBusinessEnterprise(MBE)

Yes

No

Note:Foradditionalinformationoncertification,visitthewebsite:www.pd.dgs.ca.gov/smbus

I,theundersigned,certifyanddeclarethatIhavereadalltheforegoinganswerstothispre‐qualification

questionnaireandknowtheircontents.Themattersstatedinthequestionnaireanswersaretruetothebestof

myknowledgeandbelief.IdeclareunderpenaltyunderthelawsoftheStateofCalifor

nia,thattheforegoingis

correct.

AuthorizedSignature: _______________________________ Date:___________________________

PrintName/Title: _______________________________________

click to sign

signature

click to edit

Page3of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

PART1

Part1–EssentialRequirementforQualification

(Note:Contractorshallbedisqualifiediftheanswertoquestionsnumber1through2is“NO.”)

1. Doyouhavealiabilityinsurancepolicywithpolicylim

itofatleast$1Millionperoccurrenceand

$2Millionaggregate?

_____YES _____NO

2. DoyouhaveacurrentWo

rkers’CompensationInsurancePolicyasrequiredbytheStateof

CaliforniaLaborCodeorislegallySelf‐InsuredpursuanttoLaborcodeSection3700etseq?

_____YES _____NO

(Note:Contractorshallbedisqualifiediftheanswertoquestionsnumber3thr

ough5is“YES.”)

3. Hasyourlicensebeenrevokedatanytimein thelastfive(5)years?

_____YES _____NO

4. HastheSuretyfirmcompletedacontractonyourbehalf,orpaidforcompletionbecauseyour

firmwasdefaultterminate

dbytheOwnerwithinthelastfive(5)years?

_____YES _____NO

5. AtthetimeofsubmittingthisPre‐qualificationform,isyourfirmineligibletobidonorbe

awardedapublicworkscontract,orperformasaSu

b‐contractoronapublicworkscontra ct,

pursuanttoei

therLaborCodeSection1777.1(Violationofpublicworkslaborlaws)orLabor

CodeSection1777.7(Violationofapprenticeshiprequirements)?

_____YES _____NO

IfYES,statebeginningandendingdatesoftheperiodofdebarment.

Beginning: _______________________ Ending:__________________________

NOTE:AContractordisqualifiedsolelybecauseofa“YES”answergiventoquestions3,4,or5mayappealthe

disqualificationandprovideanexplanationoftherelevantcircumstanceduringtheappealprocedure.

Page4of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

PART2

Part2–Organization,History,PerformanceCompliancewithCivilandCriminalLaw

Note:Ifanswertoanyofthefollowingquestionsis“YES,”pleaseexplainonaseparatesignedsheet.

1. Isyourfirmcurrentlyth

edebtorinabankruptcyca se?Hasyourfirmbeeninabankruptcycase

atanytimeduringthelastfive(5

)years?

_____YES _____NO

2. HasyourLicense(s)beensuspendedbytheCaliforniaStateLicenseBoard(CSLB)oranyofyour

ResponsibleManagingEmployee(RME)orOfficer(RMO)beensuspendedwithinthelastfive(5)

years?

_____YES ____

_NO

3. HasyourfirmbeenassessedandpaidLiquidatedDamagesaftercompletion ofaprojectundera

constructioncontractwitheitherpublicorprivateownerwithinthelastfive(5)years?

_____YES _____NO

4. Inthelastfive(5)years,hasyourfirm,oranyfirmwithwhichanyofyourcomp

any’sowners,

officers,orpartnerswere“associatedwith,”beendebarred,disqualified,removed,orotherwise

preventedfrombiddingon,orcompletingatanygovernmentagencyorpublicworksprojectfor

anyreason?

_____YES _____NO

5. Inthelastfive(5)years,hasyourfirmbeendenied

anawardofapublicworkscontractbased

onafindingbyapublicagencythatyourfirmwasNOTaRESPONSIBLEbidder?

_____YES _____NO

6. Inthepastfive(5)years,hasanyclaimagainstyourfirmconcerningyourfirm’s workona

constructionprojectbeenfiledincour

torarbitration?

_____YES _____NO

7. Atanytimeduringthepastfive(5)years,hasanysuretycompanymadeanypaymentsonyour

firm’sbehalfasaresultofadefaulttosatisfyanyclaimsmadeagainstaperformanceor

paymentbond

issuedonyourfirm’sbehalfinconnectionwithaconstructionproject,either

publicorprivate?

_____YES _____NO

8. Inthelastfive(5)years,hasanyinsurancecarrier,foranyformofinsurance,refusedtorenew

theinsurancepolicyforyourfirm?

_____YES _____NO

Page5of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

PART2Cont’d

9. Duringthelastfive(5)years,hasyourfirmeverbeendeniedbond coveragebyasurety

company,orhastherebeenaperiodoftimewhenyourfirmhadnosuretybon

dinplacedu

rin

apubli

cons

truction

proj

ectwhenonewas

required?

____

_YES _____NO

10. HasCALOSHAcitedandassessedpenaltiesagainstyourfirmforany“serious,”“willful,”or

“repeat”violationsofitssafetyorhealthregulationsinthepastfive(5)years?

_____YES _____NO

(Note:ifyouhavefiledanappealofacitation,andtheOccupationalSafetyandHealthAppealsBoardhasnotyet

ruledonyourappeal,youneednotincludeinformationaboutit.)

11. HasthefederalOccupationalSafetyandHealthAdministrationcitedandassessedpenalties

againstyourfirminthepastfive(5)year s?

_____YES _____NO

(Note:ifyouhavefiledanappealofacitationandtheAppealsBoardhasnotyetruledonyourappeal,orifthereisa

courtappealpending,youneednotincludeinformationaboutthecitation.)

12. HastheEPAoranyAirqualityManagementDistrictoranyRegionalWaterQualityControlBoard

citedandassessedpenaltiesagainsteitheryourfirmortheownerofaprojectonwhichyour

firmwasthecontractor,inthepastfive(5)years?

_____YES _____NO

(Note:IfyouhavefiledanappealofacitationandtheAppealsBoardhasnotyetruledonyourappeal,orifthereisa

courtappealpending,youneednotincludeinformationaboutthecitation.)

13. Hastherebeen

morethanoneoccasionduringthelastfive(5)year sinwhich yourfirmwas

requiredtopayeitherbackwagesorpenaltiesforyourownfirm’sfailuretocomplywiththe

state’sprevailingwagelaws?

_____YES _____NO

(Note:thisquestionrefersonlytoyourownfirm’sviolationofprevailingwagelaws,nottoviolationsoftheprevailing

wagelawsbyasubcontractor.)

14. Atanytimeduringthelastfiveyears,hasyourfirmbeenfoundtoviolateanyprovisionof

Californiaapprenticeshiplawsorregulations,orthelawspertainingtouseofapprenticeson

publicworks?

_____YES _____NO

(NOTE:Youmayomitreferencetoanyincidentthatoccurrediftheviolationwasbyasubcontractorandyourfirm,as

generalcontractoronaproject,hadnoknowledgeofthesubcontractor’sviolationatthetimetheyoccurred.)

Page6of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

PART3

Part3–RecentProjectsCompleted

NOTE:Contractorshallprovideinformationforaminimumofthree(3)mostrecently

completedpublicworksprojectswithinthelastthree(3)years.Namesandreferencesmust

becurrentan

dverifiable.Useseparatesheetsth atcont

ainALLofthefollowinginformation

orusethisformtolistallprojectinformation.

PROJECTINFORMATION

ProjectName: __________________________________________________________

ProjectLocation: __________________________________________________________

Owner/PublicAgency: __________________________________________________________

OwnerContactName: __________________________Title/Position:___________________

EmailAddress: __________________________CurrentPhone:__________________

ProjectDescription:

__________________________________________________________

(Sco

peofWork)

______________________

____________________________________

__________________________________________________________

___________________________________________________________

ContractAmount: $__________ ______ FinalProjectCost: _____________

ScheduledCompletion: _________________ ActualCompletion: _____________

AdditionalComments:

___________________________________________________________

(Contractormayduplicatethisformasmanytimesasnecessarytolistallprojects.)

Page7of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

PART3Cont’d

Part3–RecentProjectsCompleted

NOTE:Contractorshallprovideinformationforaminimumofthree(3)mostrecently

completedpublicworksprojectswithinthelastthree(3)years.Namesandreferencesmu

st

becurrentandverifiable.Useseparatesheetsth

atcontainALLofthefollowinginformation

orusethisformtolistallprojectinformation.

PROJECTINFORMATION

ProjectName: __________________________________________________________

ProjectLocation: __________________________________________________________

Owner/PublicAgency: __________________________________________________________

OwnerContactName: __________________________Title/Position:___________________

EmailAddress: __________________________CurrentPhone:__________________

Project

Description: ____

_________________________________

_____________________

(ScopeofWork)

__________________________________________________________

___________________________________________________________

ContractAmount: $__________ ______ FinalProjectCost: _____________

ScheduledCompletion: _________________ ActualCompletion: _____________

AdditionalComments:

___________________________________________________________

(Contractormayduplicatethisformasmanytimesasnecessarytolistallprojects.)

Page8of8

MT.SANJACINTOCOMMUNITYCOLLEGEDISTRICT

PRE‐QUALIFICATIONQUESTIONNAIRE–UPCCAA

PART3Cont’d

Part3–RecentProjectsCompleted

NOTE:Contractorshallprovideinformationforaminimumofthree(3)mostrecently

completedpublicworksprojectswithinthelastthree(3)years.Namesandreferencesmu

st

becurrentandverifiable.Useseparatesheetsth

atcontainALLofthefollowinginformation

orusethisformtolistallprojectinformation.

PROJECTINFORMATION

ProjectName: __________________________________________________________

ProjectLocation: __________________________________________________________

Owner/PublicAgency: __________________________________________________________

OwnerContactName: __________________________Title/Position:___________________

EmailAddress: __________________________CurrentPhone:__________________

Project

Description: ____

_________________________________

_____________________

(ScopeofWork)

__________________________________________________________

___________________________________________________________

ContractAmount: $__________ ______ FinalProjectCost: _____________

ScheduledCompletion: _________________ ActualCompletion: _____________

AdditionalComments:

___________________________________________________________

(Contractormayduplicatethisformasmanytimesasnecessarytolistallprojects.)

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UPCCA Contractor Questionnaire 2019 - UPCCA_Contractor_Questionnaire_2018

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Completed 18 November 2019

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