|
1 Q. to the past five years, has your firm made any claim against a project owner concerning work on a
<br />project or payment for a contract, and filed that claim in court or arbitration? ❑ Yes [K No
<br />If 'yes.- on a separate page Identify the ciaim(s) by providing the project name, date of the claim,
<br />name of the claimant, the name of the entity the Claim was filed against, a brief description of the
<br />nature of the claim, the court and case number, and a brief description of the status of the claim
<br />(pending, or it resolved, a brief description of the resolution.)
<br />11. At any ttme during the past five years, has any surety company made any payments on your firm's
<br />behaff as a result of a default, to satisfy any claims made against a performance or payment bond
<br />issued on your firm's behalf in connection with a project, either public or private? ❑ Yes ® No
<br />12, In the last live years, has any insurance carrier, for any form of insurance. refused to renew an
<br />insurance policy for your firm? ❑ Yes ® No
<br />13, Has your firm or any of its oiners, officers, or partners ever beer. liable in a Civil suit, or found guilty
<br />In a criminal action, for making any false claim or material misrepresentation to any public agency
<br />or entity? ❑ Yes X No
<br />14. Has your firm or any of its owners, officers or partners ever been convicted of a federat or state
<br />crime of fraud. theft, or any other act of dishonesty? ❑Yes MNo
<br />if eyes." identify on a separate page, the person or persons convicted, the court case and number,
<br />the crimes and the year convicted.
<br />15. It your firm was required to pay a premium of more than one percent for a performance and
<br />payment bond on any project(s) on which your firm worked at any time during the last three years,
<br />state the percentage that your firm was required to pay. If you wish to do so, you may provide an
<br />explanation for a percentage rate higher than one percent, O
<br />16, During the last five years, has your firm ever been denied bond credit by a surety company, or has
<br />there ever been a period of time when your fine had no surety bond in place during a project when
<br />one was required? ❑ Yes N No
<br />17. Has Cal -OSHA cited and assessed penalties against the contractor or its associates for any
<br />"serious," "willful' or °repeat' violations of its safety or health regulations in the past five years?
<br />❑ Yes 1M No
<br />(Note: If you have filed an appeal of a citation, and the Occupational Safety and Health Appeals
<br />Board 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,
<br />date of citation, nature of the violation, project on which the citation was Issued, owner of the
<br />project, and the amount of penalty paid, if any. State the case number and the date of any OSHAB
<br />decision.
<br />19. Has the Federal Occupational Safety and Health Administration cited and assessed penalties
<br />against the contractor or Its associates in the past five years? ❑ Yes ® No
<br />(Note: It an appeal of the citation has been filed and the Appeals Board has not yet ruled, or there
<br />is a court appeal pending, you need not Include Information about the citation.)
<br />It "yes," on a separate page describe the citation, the party against whom the citation was made,
<br />date of citation. nature of the violation, project on which the citation was Issued, owner of project,
<br />and the amount of penalty paid, if any, State the case number and date of any decision.
<br />Pa700
<br />PO Janitorrnl Serv4O
<br />
|