Fillable UPCCAA PreQualification Questionnaire for 2020 Calendar Year (Mt. San Jacinto Community College District)

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UPCCAA PreQualification Questionnaire for 2020 Calendar Year (Mt. San Jacinto Community College District)

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MT. SAN JACINTO COMMUNITY COLLEGE DISTRICT

1499 N. STATE ST, SAN JACINTO, CA 92583

UPCCAA Pre‐Qualification Questionnaire for 2020 Calendar Year

CONTRACTOR INFORMATION

Firm Na

me: ______________________________________________________________________

(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 name: ______ 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/

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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 In terest: ___________________________________________________

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

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: _______________________________________

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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 Workers’ 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 through 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 terminated 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 contract,

pursuant to either 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.

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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 case? 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 company’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 court 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

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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) 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.)

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) years 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 5 of 8

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             

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 that contain ALL of the following information

or use this form to list all project information.

Project Name:

Project Location:

Owner/Public Agency:

Owner Contact Name:

Email Address:

Project Description:

(Sco

pe of Work)

Contract Amount:

Scheduled Completion:

Additional Comments:

PROJECT INFORMATION

__________________________ Title/Position: ___________________

__________________________ Current Phone: __________________

$________________ Final Project Cost: _____________

_________________ Actual Completion: _____________

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

Page 6 of 8

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  __________________________________________________________ 

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     

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______________________________________________________ 

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__________________________________________________________ 

___________________________________________________________ 

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     

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___________________________________________________________ 

             

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

be current and verifiable. Use separate sheets that contain ALL of the following information

or use this form to list all project information.

Project Name:

Project Location:

Owner/Public Agency:

Owner Contact Name:

Email Address:

Project

Description:

(Scope of Wo rk)

Contract Amount:

Scheduled Completion:

Additional Comments:

PROJECT INFORMATION

__________________________ Title/Position: ___________________

__________________________ Current Phone: __________________

$________________ Final Project Cost: _____________

_________________ Actual Completion: _____________

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

Page 7 of 8

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  __________________________________________________________ 

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______________________________________________________ 

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__________________________________________________________ 

___________________________________________________________ 

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     

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___________________________________________________________ 

             

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

be current and verifiable. Use separate sheets that contain ALL of the following information

or use this form to list all project information.

Project Name:

Project Location:

Owner/Public Agency:

Owner Contact Name:

Email Address:

Project

Description:

(Scope of Wo rk)

Contract Amount:

Scheduled Completion:

Additional Comments:

PROJECT INFORMATION

__________________________ Title/Position: ___________________

__________________________ Current Phone: __________________

$________________ Final Project Cost: _____________

_________________ Actual Completion: _____________

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

Page 8 of 8

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UPCCAA PreQualification Questionnaire for 2020 Calendar Year (Mt. San Jacinto Community College District)

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Completed 5 September 2020

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