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t 4 <br />SECTION 00456 — QUALIFICATIONS QUESTIONNAIRE <br />NOTICE: THE OWNER RETAINS THE DISCRETION TO REJECT THE BIDS OF NON - <br />RESPONSIBLE BIDDERS. <br />UNDER PENALTY OF PERJURY, the undersigned Bidder Guarantees the truth and accuracy <br />of all statements and answers herein contained. Failure to comply with these requirements <br />may be considered sufficient justification to disqualify a Bidder. Attach additional sheets as <br />required. <br />Documentation Submitted with Project No: 1139 <br />Project Name: CR512 WESTBOUND RESURFACING (ROSELAND ROAD TO USI) AND <br />CR512 EASTBOUND RESURFACING (EASY STREET TO USI) <br />1. Bidder's Name / Address: p ‘ tiVityl-t1QpGC.A <br />V 3(O Skal O\cfl p �a y,Zu l to Verb Q32 t Q2 <br />2 Bidder's Telephone & FAX Numbers: 71Z,,,S1/4.1 1703/172.VA <br />3. Licensing and Corporate Status. <br />a. Is Contractor License current? <br />b. Bidder's Contractor License No SCOSZ 40 [Attach a copy of Contractor's <br />License to the bid] <br />c. Attach documentation from the State of Florida Division of Corporations that <br />indicates the business entity's status is active and that lists the names and titles of <br />all officers. <br />4. Number of years the firm has performed business as a Contractor in construction work <br />of the type involved in this contract: 37 <br />5 What is the last project OF THIS NATURE that the firm has completed? <br />6. Has the firm ever failed to complete work awarded to you? n O <br />[If your answer is "yes", then attach a separate page to this questionnaire that explains <br />the circumstances and list the project name, Owner, and the Owner's telephone number <br />for each project in which the firm failed to complete the work.] <br />7. Has the firm ever been assessed liquidated damages? no <br />[If your answer is "yes", then attach a separate page to this questionnaire that explains <br />the circumstances and list the project name, Owner, and the Owner's telephone number <br />for each project in which liquidated damages have been assessed.] <br />8. Has the firm ever been charged by OSHA for violating any OSHA regulations? (\O <br />00456 - Qualifications Questionnaire <br />00456 - 1 <br />F'1Public Works\ENGINEERING DIVISION PROJECTS\1139-CR 512 Wbnd Resurfacing -Roseland Rd to US 1-SCOP\Admimlbid documents\Master Contract <br />Documents100456 - Qualifications Questionnaire.doc <br />