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If "yes," on a separate page identify the claim(s) by providing the project name, dale of the claim, name of
<br />the claimant, the name of the entlty 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 past five years, has your firm made any claim against a project owner concerning work on an.ect
<br />or payment for a contract, and filed that claim in court or arbitration? ❑ Yes No
<br />If "yes," on a separate page Identify the clahn(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 />11. At any time 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 Issued on
<br />your firm's behalf In connection with a project, either public or private? ❑ Yes N No
<br />12. In the last five years, has any Insurance carrier, for any form of insurance, refused to renew the insurance
<br />policy for your firm? ❑ Yes X 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 />F�1
<br />14. Has your firm or any of its owners, officers or partners ever been convicted of a federal or state crime of
<br />fraud, theft, or any other act of dishonesty? ❑ Yes JA No
<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 performance and payment
<br />bond on any project(s) on which your firm worked at any time during the last three y ears, state the
<br />percentage that your firm was required to pay. Yot may provide en explanation for a percentage rate
<br />higher then one percent, if you wish to do so, 9-A %
<br />18. During the last five years, has your firm ever been denied bond credit by a surety company, or has there
<br />ever been a period of time when your firm had no surety bond in place during a project when one was
<br />required? ❑ Yes K No
<br />17, Has Cal -OSHA cited and assessed penalties against the contractor or its associates for any "serious,"
<br />"willful" or "repeat" violations of its safety or health regulations in the past five years? ❑ Yes X No
<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 citations, the party against whom the citation was made, date of
<br />citation, nature of the violation, project on which the citation was issued, owner of the project, and the
<br />amount of penalty paid, if any. State the case number and the dale of any OSHAB decision.
<br />18. Has the Federal Occupational Safety and Health Administration cited and assessed penalties against the
<br />contractor or its associates in the past five years? ❑ Yes O� No
<br />City of Santa Ana - Public Works Agency
<br />Construction Surveying Services RFP
<br />Page 28 (ADDENDUM NO. 3)
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