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SECTION 00456 - QUALIFICATIONS QUESTIONNAIRE NOTICE: THE OWNER RETAINS THE DISCRETION TO REJECT THE BIDS OF NON - RESPONSIBLE BIDDERS. UNDER PENALTY OF PERJURY, the undersigned Bidder Guarantees the truth and accuracy of all statements and answers herein contained. Failure t0 Comply with these requirements may be considered sufficient justification to disqualify a Bidder. Attach additional sheets as required. Documentation Submitted with Project No: 1232 Project Name: 18t Street S.W. and 43'd Avenue Intersection Improvements 1. Bidder's Name / Address: Blue Goose Construction LLC 9901 Okeechobee Road Fort Pierce, FL 34945 2. Bidder's Telephone & FAX Numbers: (772)461-3020 Fax (772)468-4669 3. Licensing and Corporate Status: a. Is Contractor License current? Yes b. Bidder's Contractor License No: CGC1522900 [Attach a copy of Contractor's License to the bid] c. Attach documentation from the State of Florida- Division of Corporations that indicates the business entity's status is active and that lists the names and titles of all officers. 4. Number of years the firm has performed business as a Contractor in construction work of the type involved in this contract: 15 years 5. What is the last project OF THIS NATURE that the firm has completed? FOA - The City of Fellsmere, Florida Organic Aquaculture, Entrance Drives, see attached FOA project Ref Sheet. St. Lucie and Indian River County Continued Service Contracts see attached project ref sheets 6. Has the firm ever failed to complete work awarded to you? No [If your answer is 'yes", then attach a separate page to this questionnaire that explains the circumstances and list the project name, Owner, and the Owner's telephone number for each project in which the firm failed to complete the work.] 7. Has the firm ever been assessed liquidated damages? No [If your answer is "yes", then attach a separate page to this questionnaire that explains the circumstances and list the project name, Owner, and the Owner's telephone number for each project in which liquidated damages have been assessed.] 8. Has the firm ever been 'charged by OSHA for violating any OSHA regulations? No [If your answer is "yes", then attach a separate page to this questionnaire that explains the circumstances and list the project name, Owner, and the Owner's telephone number for each project in which OSHA violations were alleged.] 00456 - Qualifications Questionnaire.doc 00456 -1 F:\Public Works\ENGINEERING DIVISION PROJECTS \1232 -1st St SIN 43rd Ave Intersec Improv\Admlmlbld documents\Master Contract Documents\00456 - Qualifications Ouestionnaire.doc