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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 to comply with these requirements may be considered sufficient justification to disqualify a Bidder. Attach additional sheets as required. Documentation Submitted with Project No: 1619 Project Name: ROUND ISLAND RIVERSIDE PARK PAVEMENT RESURFACING 1. Bidder's Name I Address: Community Asphalt,Corp 2975 Industrial Blvd.,Vero Beach FL 32967 2. Bidder's Telephone & FAX Numbers: ph: (772)770-3771,fax: (772)770-3707 3. Licensing and Corporate Status: a. Is Contractor License current? Yes b. Bidder's Contractor License No: CGC1521192 [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: 36 5. What is the last project OF THIS NATURE that the firm has completed? Please see attached list of projects completed 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.] 00455-Qualifications Questionnaire 00456-1 FAPublic Works%ENGINEERING DMSION PROJECTS11619 Round Island Feality PwAnMt-Adrn"bid documetftWaster Contrad Documents=456-Qualifications Quostionnaire.doc i