Request for General Contractor Prequalification Submittals ? B121 Burlington Lab Renovation

Pursuant to the statute, this form gathers information about the contractors seeking to qualify for the work and provides a general format for the prequalification criteria. Completing this questionnaire does not guarantee prequalification. Evaluation of the submittal shall be performed by the prequalification committee in accordance with 143-135.8 and the State of NC Prequalification Policy (attached).

Contractors are not to use the blank template from the SCO website but to use the project specific form from the Prequalification Committee.

PREQUALIFICATION DUE DATE/TIME:

Project Description:

The B121 Burlington Lab Renovation project located on North Campus. This project renovates 4,163 square feet of

vacated shop space in the basement into wet-research labs in Burlington Labs (built 1953, with a 1973 addition) to

accommodate three new faculty researchers. The project includes architectural, mechanical, electrical and plumbing.

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SECTION 1. GENERAL COMPANY INFORMATION

1. a. Primary/Main office location (from where the project will be managed)

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Company Name

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Physical Address

________________________________________________________________________________________________________________________________

Mailing Address

________________________________________________________________________________________________________________________________

City/State Zip Code + 4

(______ )_____________________________________ (_____ ) ________________________________________

Phone number Fax number

______________________________________________________________ ________________________________________________________________

Primary Contact Name Secondary Contact Name

______________________________________________________________ _______________________________________________________________

Primary Contact Email Address Secondary Contact Email Address

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

Organization

1. b. Business type (check box) Corporation Partnership Limited Liability Company Sole Proprietor Joint

Venture

Indicate your NC Statewide Uniform Certification: (check box): MBE HBE AABE AIBE WBE SDB DBE

See website link for more information: http://www.doa.nc.gov/hub/swuc.htm

_______________________ Other (specify) ______________________ Certifying Agency/State (specify)

Is your firm registered with the State of North Carolina to do business? Yes No

Is your firm owned or controlled by a parent or any other organization? Yes No

Describe Ownership if Yes:_______________________________________________________________________

List all other names your firm has operated as for the past five (5) years: __________________________________

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

1. c. Licensing Information (Please provide all North Carolina professional licenses required for you to perform your services.)

NC License number/name of licensee License Limit/Level State/County/City Privilege License (provide copy)

_______________________________ _________________ _________________________________________

_______________________________ _________________ _________________________________________

_______________________________ _________________ _________________________________________

Has any license ever been denied or revoked? Yes No If yes, please describe, ________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

1. d. Type of Work Performed on a regular basis

Primary Scope of Work: _________________________________________________________________________

Secondary Scope of Work: _______________________________________________________________________

Other Scope of Work: ___________________________________________________________________________

What type of work do you self perform?____________________________________________________________

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

Bonding

1. e. (1) Attach letter, dated within the last 30 days, from your surety company, signed by their Attorney in Fact, verifying their willingness to issue sufficient payment and performance bonds for this project, on behalf of your firm and the dollar limits of that bond commitment, both single and aggregate. Surety company bond rating shall be rated "A" or better under the A.M. Best Rating system or The Federal Treasury List.

Have you attached a surety letter? Yes No

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

1. e. (2) Have funds been expended by a surety company on your company's behalf within the past 10 years?

Yes No If yes, explain...

_____________________________________________________________________________________________

_____________________________________________________________________________________________

[Matrix: 0-3 points. If no funds expended by surety company give 3 points. If not, give 0 points.]

Insurance

1. f. The minimum requirements of coverage are listed in Article 34 of the State Construction General Conditions. Firms must indicate that they can provide evidence of insurance coverage, should they be the successful bidder by attaching a copy of their insurance certificate. Have you attached a copy of your insurance certificate? Yes No

Workers Compensation Insurance as required by law and Employer's Liability Insurance Coverage with minimum limits of $100,000.

Comprehensive general liability with minimum limits of $500,000 per occurrence for bodily injury and $ 100,000 per occurrence/$300,000 aggregate for property damage.

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

Financials

1. g. Attach latest balance sheet and income statement, if available, based on company type. Audited statements preferred. If not available, attach a copy of the latest annual renewal submission to the relevant licensing board. (Company must submit financial data and must clearly indicate "confidential" on the document to avoid this item from becoming part of a public record.) Have you attached a balance sheet? Yes No

[Matrix: Pass/fail. If information provided, then continue with evaluation. If not, disqualify.]

Barred from Bidding

1. h. Is your present company, its officers, owners, or agents currently barred from bidding public work in North Carolina? Yes No

[Matrix: Pass/fail. If "Yes", disqualify.]

SECTION 2. GENERAL REQUIREMENTS

Experience - Size/Capacity/Workload

2. a. (1) List the annual dollar value of construction work the company has completed and has under contract for each year over the last (3) three calendar years (if applicable). If three years of data cannot be provided, please explain.

[Matrix: 0-3 points. For each year completed give 1 point each.]

2. a. (2) How many projects do you currently have under contract or in progress and what is their total dollar value?

(# of projects);

$ (Current projects contract amount);

$ (Projects current amount remaining to bill)

[Matrix: 0-3 points. If section completed give 3 points. If not, give 0 points.]

2. a. (3) What was your largest single project completed in the past five years? Sq. Ft. $ (Dollar Amount)

Location Year Completed

[Matrix: 0-4 points. Take the "dollar amount of largest job completed" and multiply by 1.5. If the result is larger than the estimated project cost, then give 4 points. If the result is within 10%, then give 3 points. If the result is within 15%, then give 2 points. If the result is within 20%, then give 1 point. Otherwise, give 0 points.]

2. a. (4) Projects Current Amount Remaining to Bill (from 2.a.2 above) $ ________ (Dollar Amount)

[Matrix: 0-4 points. Take "projects current amount remaining to bill" dollar amount and add the estimated construction cost of the project advertised. Compare total amount to the aggregate bonding capacity in the Surety Letter (1.e.1). If amount is within the company's bonding capacity, then give 4 points. If not, give 0 points.]

2. a. (5) List the three largest contracts currently under contract or in progress, including for each, the name of the project, owner, architect and/or GC/CMR and contact information below.

[Matrix: 0-9 points. For each project above, give 2 points for each positive reference from the owner and 1 point from the architect/designer.]

Office Locations

2. b. Will this project be managed and directed from an office in NC? An office in NC is defined as "The principal place from which the trade or business of the bidder is directed or managed," per GS 143-59 (c). Yes No

[Matrix: 0-4 points. If office location is managed and directed from NC office give 4 points. If not, give 0 points.]

Litigation/Claims

2. c. (1) Has your company had any judgments entered against it or been the target of a suit by an owner in a construction project within the past 10 years, whether resolved or still pending resolution? Yes No

[Matrix: 0-2 points. If company has not been involved in any of the above, give 2 points. If they have, give 0 points.]

2. c. (2) Are there currently any judgments or suits pending or outstanding against your company, its officers, owners, or agents arising from a construction project? Yes No

[Matrix: 0-2 points. If there are no current judgments, claims, arbitration, suits, or mediation pending give 2 points. If there is, give 0 points.]

2. c. (3) Has your company ever been terminated from a construction project or otherwise defaulted or removed from a construction project within the past 10 years? Yes No

[Matrix: 0-3 points. If company has never failed to complete work, it has been awarded give 3 points. If they have failed to complete work, give 0 points.]

2. c. (4) Have you or your company ever paid liquidated damages on a state project within the past 10 years? Yes No

[Matrix: 0-3 points. If "Yes", give 0 points. If "No," give 3 points.]

2. c. (5) Has your company, its officers, owners, or agents ever been convicted of conflicts of interest, bribery, bid rigging, fraud, misappropriation, embezzlement, false claims, or other financial crimes within the past 10 years?

Yes No

[Matrix: 0-3 points. If "Yes," give 0 points. If "No," 3 points.]

Safety Record

2. d. List your company's Experience Modification Rate (EMR) for the past three years. (Attach OSHA 300 Log for the last 3 years.) Have you attached OSHA 300 log? Yes No

Present EMR Rate Previous Year's EMR Rate EMR rate of two years ago

If these rates reflect corporate performance over several locations, please explain, to the extent possible, the performance experience of the location serving this project: __ _____

________________________________________________________ _____

List any OSHA fines and Jobsite fatalities in the past 3 years with an explanation: _____

______________________________________

[Matrix: 0-5 points. If EMR rate for each of the past three years is less than or equal to 1 then give 5 points. If not, give 0 points.]

Historically Underutilized Business (HUB) Plan and Record

2. e. Does the company currently have a documented plan for engaging subcontractor participation from Historically Underutilized Businesses? Yes No. If yes, please attach.

List the company's three highest HUB participation percentages on projects completed within the last three years?

Project #1____________________________________________________________ HUB Participation _______% Project #2____________________________________________________________ HUB Participation _______% Project #3____________________________________________________________ HUB Participation _______%

[Matrix: 0-5 points. If company has a current documented plan and has attached the plan give 2 points. If not, give 0 points. Give 1 point for each project listed with HUB participation % shown for each.]

SECTION 3. PROJECT SPECIFICS

3.a. The assigned project superintendent for this project shall be:______________________. Include a professional resume, including but not limited to education, training, certifications, similar project experience and owner/architect references (name, phone number and email address). Have you included a resume and references? Yes No

If the assigned superintendent cannot be guaranteed for this project, please provide an alternate superintendent (with resume and references).

[Matrix: 0-5 points. If resume included, give 3 points. If positive reference is received, give 2 points.]

3.b. The experience this superintendent has on similar types of projects as evidenced by their resume is:

___ 0-2 ___ 3-4 ___ 5-10 ___ >10 years.

[Matrix: 0-5 points. If 0-2 years give 2 pts, 3-4 years give 3 pts, 5-10 years give 4 pts, >10 years give 5 pts.]

3.c. The assigned project manager for this project shall be: ______________________________. Include a professional resume, including but not limited to education, training, certifications, similar project experience and owner/architect references (name, phone number and email address). Have you included a resume and references? Yes No

If the assigned project manager cannot be guaranteed for this project, please provide an alternate project manager (with resume and reference).

[Matrix: 0-5 points. If resume included, give 3 points. If positive reference is received, give 2 points.]

3.d. The experience this project manager has on similar types of projects as evidenced by their resume:

___ 0-2 ___ 3-4 ___ 5-10 ___ >10 years.

[Matrix: 0-5 points. If 0-2 years give 2 pts, 3-4 years give 3 pts, 5-10 years give 4 pts, >10 years give 5 pts.]

Similar Projects

3.e. List three (3) current or completed projects of similar type which most closely reflect the size and complexity of the type of work being requested for the currently proposed project within the last 10 years.

[Matrix: 0-18 points. For each similar project listed above, give 2 points ONLY if the project is similar in scope and size. In addition, for each project above, give 2 points for each positive reference from the owner and architect/designer. In addition, give 2 points for each successful project defined by timely completion and satisfactory job performance.]

3.f. List the three most current or completed projects with NC State University within the past five years. Please list the project name, project executive, project manager and superintendent. Please provide the owning agency/institution point of contact for the project.

[Matrix: 0-9 points. For each project performed (listed), give 3 points for each project successfully completed on time, within budget and a positive reference by the owner. If company has not completed at least 3 projects for the owner, points will not be deducted for lack of a first, second or third project.]

SECTION 4. SIGNATURE

By signing this document, you are acknowledging that all answers are true to the best of your knowledge. Any answers found to be falsified will bar you from being prequalified on this project.

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Company Name (as licensed in NC)

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Physical Address

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Mailing Address

Dated this day of:

Submitted by:

Signature by Authorized Officer Print Title of Authorized Officer

Phone:____________________________________________

Contact person's phone number

E-mail:_____________________________________________

Contact person's E-mail address

Notary Certification:

North Carolina

County

I, a Notary Public of the County and State aforesaid, certify that , personally appeared before me this day and acknowledged the execution of the foregoing instrument. Witness my hand and official seal, this the day of , 20 .

(Official Notary Seal or Stamp)

Signature of Notary Public

My commission expires , 20

[Matrix: Pass/fail. Signature section must be fully executed with notary information provided for company to be prequalified. If not, then disqualify.]