Contractors’ List for Emergency WorkFebruary 2005

QUESTIONNAIRE

Instructions: Fill-in all information and check all boxes that apply. Attach additional pages as necessary. Sign certification statement at the end and submit per the announcement.

  1. Company Name:

  1. Name of Owner/s:

  1. Company Mailing Address:

  1. Company Office Address (if different from above):

  1. Office Phone No.:

  1. Office Fax No.:

  1. Email Address:

  1. What is/are your valid Contractor’s License/s in the State of California? (Check all that applies and complete information on the right columns. Attach additional page if needed.)

Class A, General Engineering Contractor……
Class B, General Building Contractor……….
Class C-5…………………………………….
Class C-8…………………………………….
Class C-10……………………………………
Class C-12……………………………………
Class C-20……………………………………
Class C-27……………………………………
Others:
Others:
Others:
/ License Number:
/ Expiration Date:
  1. Type of work you are capable and qualify to perform: (Check all that applies. Attach additional page if needed.)

Paving work (including grinding, base repair, sidewalk, curb, curb ramps, etc.)
Water main installation work
Sewer related work
Traffic signal work
Street lighting work
Building construction
Seismic upgrade of buildings
Bridge construction
Roof repair
Elevator repair
Window/Door repair
Earthwork
Demolition / Muni rail construction
Landscape and irrigation
High pressure (AWSS) hydrant and main installation
Low pressure hydrant work
Industrial building construction
Hot water system
Slope stabilization
Dredging
Hazardous Material Removal
Shoring
Others:
Others:
Others:
  1. Will you be able to provide proof of valid insurance for the minimum requirement stated below prior to start of work?
/ Yes / No
CONTRACTOR’S LIABILITY INSURANCE: Contractor shall have in full force and effect, for the period of each emergency work awarded, the following liability insurance with the following minimum specified coverages or coverages as required by laws and regulations, whichever is greater:
1.Worker’s compensation, including employers’ liability coverage with limits not less than $1,000,000.00 each accident and $1,000,000.00 aggregate.
2.Commercial general liability insurance with limits not less than $1,000,000.00 each occurrence combined single limit for bodily injury and property damage, including coverage for contractual liability, independent contractors, explosion, collapse, and underground (XCU), broadform property damage, and completed operations.
3.Business automobile liability insurance with limits not less than $1,000,000.00 each occurrence combined single limit for bodily injury and property damage, including owned, hired or non-owned vehicles, as applicable.
Commercial General Liability and Business Automobile Liability Insurance policies shall be endorsed to provide the following:
(1)Name as Additional Insured the City and County of San Francisco, its Officers, Agents, and Employees.
(2)That such policies are primary insurance to any other insurance available to the Additional Insureds, with respect to any claims arising out of this contract, and that insurance applies separately to each insured against whom claim is made or suit is brought.
All policies shall be endorsed to provide:
Thirty (30) days' advance written notice to City of cancellation or non-renewal, mailed to the following address:
Contract Clerk
Department of Public Works
Division Of Contract Administration
875 Stevenson Street, Room 420
San Francisco, CA 94103
  1. Do you certify that you will pay your workers the prevailing wage rate?
/ Yes / No
  1. Provide twenty-four hour Emergency Contact Information, minimum of two (to be used by the City for emergency work):

Contact Person #1:
Name:
Work Phone No.:
Cellular Phone No.:
Pager No.:
/ Contact Person #2:
Name:
Work Phone No.:
Cellular Phone No.:
Pager No.:
  1. Provide a minimum of 2 references from Public or Private Owners:

Reference #1:
Name:
Company:
Phone No.:
/ Reference #2:
Name:
Company:
Phone No.:
  1. Do you have a current San Francisco Business Tax Registration Certificate Number? If yes, list Business Tax Registration Certificate No.:

/ Yes / No
  1. If you don’t have a business tax number, will you be able to obtain one before start of work?
/ Yes / No
  1. Do you have a current City Vendor Number? (Vendor numbers are required to certify contracts and receive payments.)
If yes, list vendor number:
If no, be prepared to submit the following information to obtain a Vendor Number: FEIN, W-9 and HRC Form 3. / Yes / No
  1. Are you compliant with the City’s 12B Ordinance regarding Nondiscrimination in Contracts and Benefits?
/ Yes / No
  1. If your firm is not compliant with the 12B Ordinance, will you file for compliance with the 12B Ordinance when approved for placement on the emergency list? Please contact the HRC's 12B Unit at (415) 252-2500 for forms and instructions.
/ Yes / No
  1. Have you ever been debarred from a government agency? If yes, list the date and explain the reasons:

/ Yes / No
  1. Have you ever been suspended from doing work with any Owner? If yes, list the date and explain the reasons:

/ Yes / No
  1. Have you ever been cited for any OSHA violations? If yes, list the date and explain the reasons:

/ Yes / No
  1. Are you willing and able to mobilize with the requisite resources to commence work within 2 to 4 hours of notification to proceed from the City?
/ Yes / No
  1. Do you have a storage yard or business office in the City and County of San Francisco? If yes, list the Field Office or Storage Yard Address:

/ Yes / No
  1. Are you willing to provide the City with updated information whenever necessary to keep the information in the list up to date?
/ Yes / No
  1. Have you performed any emergency work in the last 10 years? If yes, list the owner, project location, date performed, and nature of emergency work:

/ Yes / No
  1. Are you currently certified as a “Local” DBE firm with the San Francisco HRC?
/ Yes / No

I certify that the information provided in this Questionnaire is true and accurate to the best of my knowledge.

______

SignatureDate

Print Name and Title

END OF QUESTIONNAIRE

Questionnaire: Page 1 of 4