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If "yes," on flseparate page Identify the dalm(s) by providing the project name, date of the claim, name of
<br />the claimant, the name of the entity the claim was filed against, a brief description of the nature of the
<br />claim, the court and case number, and a brief description Of the status of the claim (pending or, if
<br />resolved, a brief description of the resolution.)
<br />10. In the post five years, has your firm made any claim against a project owner concerning work on a oJect
<br />or payment for a contract, and filed that claim in court or arbitration? El Yes ?i No
<br />If "yes," on a &operate page Identify the clolm(s) by providing the project name, date of the claim, name of
<br />the claimant, the name of the entity the claim was filed Against, a brief description of the nature of the
<br />claim, the court And case number, and a brief description Of the Status of the claim (pending or, ff
<br />resolved, a brief description of the resolution•)
<br />11. At anytime during the past five years, has any surety company made any payments on your firm's behalf
<br />as a result of a default, to satisfy any claims made against A performance or payment bond Issue on
<br />your firm's behalf In connection with a project, either public or private? 0 Y V No
<br />12, In the last five years, has Any insurance carrier, for zany form of insurance, refused to renew the Insur nee
<br />policy for your firm? D Yes ff No
<br />13. Has your firm or any of Its owners, officers, or partners ever been liable In a civil suit, or found guilty in a
<br />criminal action, for making any false claim or material misrepresentation to Any public agency, or entity?
<br />0 Yes Qr No
<br />14. I-Ici; your firm or any of Its Owners, officara or partners ever been convicted of A federal or state crime of
<br />fraud, theft, or any other act of dishonesty? 0 Yes VNo
<br />If "yes,' Identify on a separate page, the person or persons convicted, the court case and number, the
<br />crimes and the year convicted.
<br />15. If your firm was required to pay a premium of more than one percent for a performonoo and payment
<br />bond on Any projeot(s) on which your firm worked at any time during the last three years, state the
<br />percentage that your firm was required to pay. You may provide an explanation for a percentage rate
<br />higher then one percent, If you wish to do so, ........... ELA__
<br />16. During the lost five years, has your firm ever been denied bond credit by a surety company, or has there
<br />ever been a period of Urne when your firm had no surety bond In place during a project when one was
<br />required? 0 Yes No
<br />'17. Has Cal-OSI-A cited And assessed penalties Against the contractor or its associates for any "serious
<br />WIlful" or "repeat" violations of its safety or health regulations In the past five years? [] yes 9 N�
<br />(Note: if you have filed an appeal of A citation, and the Occupational Safety And Health Appeals Board
<br />has not yet ruled on your appeal, you need not include Information about It.)
<br />If "yes," on a separate page describe the cliations, the party against whom the citation was made, date of
<br />citation, nature of the violation, project on which the OitatlOri Was Issued, owner of the project, and the
<br />Amount of penalty paid, if any. State the case number and the date of any OSHAB decision.
<br />18. Ilea the Federal Occupational Safety and Health Administration cited end assessed penalties again the
<br />contractor or Its associates In the past five years? We
<br />struction Surveying Services r
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