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929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651
Complete this form (adding attachments as needed) to provide a basis for evaluation of your firms qualifications. Subcontractors / Vendors / Service Providers (referred to herein as the Firm) should complete this Subcontractor Qualification Questionnaire (Questionnaire) as requested by us (referred to herein as the Company). This Questionnaire will be valid for a period of two (2) years from date of execution or until significant changes occur to data provided (whichever is shorter). Provided the Firm has a valid Questionnaire on file, the Firm will not have to complete a new Questionnaire. Other project specific forms, however, must still be completed as requested. 1. General Information: Business Entity Name (the Firm): __________________________________________________________________ Firm Street Address: ______________________________________________________________________________ City: ______________________________________________ State: ________________ Zip: ________________
Firm Mailing Address (if different): __________________________________________________________________ City: ______________________________________________ Telephone: ________________________________________ Contact Person: _____________________________________ Email Address: ______________________________________ Tax ID #: ______________________________ Primary NAICS Code: ____________________ State: ________________ Zip: ________________ Fax: _______________________________________ Title: ______________________________________ Website:___________________________________ State of Origin: __________ Union (Y/N): ____________
Geographic Area(s) or State(s) Can Work: _____________________________________________________________ Prior Foreign Capabilities (Y/N): __________ Specify Country(ies): ________________________________________ _______________________________________________________________________________________________
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 Contractors License(s) - (Attach separate sheet of necessary): State License No. State License No.
[ ] Partnership
[ ] Sole Proprietorship
[ ] Other: ___________________________________
If Firm is a Joint Venture, provide list of all partner firms and/or parties to the Joint Venture: Partner/Party Name % of Ownership
0%
0%
0%
0%
(This Questionnaire must also be completed by each Joint Venture Partner/Party noted in the table above.) 3. Type of Business (Check all that apply): [ ] Testing Agency [ ] Subcontractor [ ] Architecture [ ] Engineering [ ] Consulting [ ] GC/CM
4. Business Classifications: Check ALL that apply (provide copy/proof of certification*). Refer to definitions provided. 4a. Small Business Administration (SBA) Classifications: business-size-standards for size standard thresholds) (refer to http://www.sba.gov/content/table-small-
[ ] SB (if you didnt check SB, proceed to section 2b without checking the remaining options within section 2a.) [ ] SDB [ ] WOSB [ ] HUBZoneSB* [ ] VOSB [ ] SD-VOSB (also check VOSB and SB)
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 4b. Other Business Classifications: (NOTE: ANC, IEE, & TO auto qualify as SB & SDB, regardless of size. If you checked ANC, IEE, or TO, also check SB & SDB in section 4a above. ANC and IEE are also TO. If you checked ANC or IEE, also check TO.)
[ ] ANC (Alaskan Native Corporation) [ ] IEE (Indian Economic Enterprise) [ ] TO (Tribally Owned) [ ] DBE* [ ] NHO 4c. [ ] MBE* [ ] HBCU/MI
[ ] WBE* [ ] AbilityOne
[ ] SBE*
[ ] VOB
[ ] DVBE
[ ] Other ______________________________
Ever been denied, decertified, or graduated out of any certification program(s) (Y/N): ____________________
If YES, Explain: _________________________________________________________________________________ _______________________________________________________________________________________________ 4d. Applications pending for any certification program(s) (Y/N): ______________ If YES, provide details below Certification Name / Type Date Application Submitted Certifying Agency
5. Bonding:
Project Limit: $ _________________________________ Aggregate Limit: $ ________________________________ Bonding Co.: _______________________________________ Since: ____________ A.M. Best Rating: ________
Phone: __________________________
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 6. Insurance (select all that apply): [ ] Work. Comp. [ ] G.L. [ ] Auto [ ] Excess Umbrella
(Provide sample Insurance Certificate, showing limits for above coverages.) Insurance Co.: ______________________________________ Since: ____________ A.M. Best Rating: ________
Broker / Agent: _______________________________________________ 7. Safety: Written Safety Program (Y/N): _________ Current Yr: _____________ Current Yr: _____________
Phone: __________________________
OSHA 30 Hr. Trained Employees (Approx. Qty.): __________ Prior Yr: ________________ 2 Yrs. Prior: ______________ Prior Yr: ________________ 2 Yrs. Prior: ______________ Approx. Work Backlog Value: $ _______________________
8. Financial:
Smallest / Largest Proj. Comfortable Handling: $ _______________________ / $ ___________________________ 9. Gov. Clearances: FCL Facility Clearance (Y/N): ______ PCL Personal Clearances (Y/N Qty): ______ / ______
FSO Facility Security Officer: _____________________________ _______________________________________ (name) (email) 10. Office Facilities (check one): [ ] Own [ ] Lease/Rent (provide additional information below)
Office Facility Owners Name: __________________________________________________________________________ Street Address: _____________________________________________________________________________________ City: ___________________________________________________ State: ____________ Zip: _________________
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 11. Does Firm share office space, staff, or equipment (including phone exchanges) with any other business(es) or organizations (Y/N): _________ If YES, list below: Entity Name Tax ID # Description and Basis for Share
13. Recently Completed Projects (5 most recent): Project Name / Your Scope Client Name Contract Value Completion Date
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 14. Largest Projects (3 largest): Project Name / Your Scope Client Name Contract Value Completion Date
16. Select all items (Pages 7-12) that your Firm self-performs with own forces (Check ALL that apply from Pages 7-12) 17. What items of work are typically subcontracted by your Firm? ____________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Equipment Rentals
Cleaning / Janitorial Services Site Protection Rodent / Pest Control Security Guard Services Safety Consulting Safety Equip. / Supplies
Contam Site Mtrl Removal (Special Waste or Contaminated Soils) 0262 Underground Storage Tank Removal
027 028
Water Remediation (Treatment or Decontamination) Facility Remediation (Asbestos, Lead, Mold, etc.)
QAQC Consulting Office Supplies & Equip Messenger Services Office Furniture
Precast Concrete 0341 Precast Structural Concrete (PSC) PSC Hollow Core Plank PSC Slabs PSC Tees PSC Stairs PSC Girders
Printing / Doc Mgmt Services Photographic Services Arch. / Eng. / Consulting Services Surveying Scheduling Geotechnical Structural Testing Legal Architectural
03.4713 03.4716
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 ONLY SELECT THE ITEMS THAT YOU HAVE ABILITY TO SELF-PERFORM WITH OWN FORCES 0353 038 Concrete Toppings 07.5300 07.5400 07.5500 07.5600 07.5700 07.5800 078 Elastomeric Membrane Rfng Thermoplastic Membr Rfng Protected Membrane Rfng Fluid-Applied Roofing Coated Foamed Roofing Roll Roofing
04 MASONRY 05 METALS 051 052 053 054 055 057 061 062 064 065 066 067 068 Structural Metal Framing Metal Joists Metal Decking Cold-Formed Metal Framing Misc Metals Decorative Metals 079 Rough Carpentry Finish Carpentry Arch Wdwrk or Casework (Fab / Sales) Structural Plastics (Fab / Sales) Plastics (Fab / Sales) Structural Composites (Fab / Sales) Composites (Fab / Sales) 083
Fire & Smoke Protection 07.8100 07.8400 07.8600 07.9100 07.9200 07.9500 Applied Fireproofing Firestopping Smoke Seals Preformed Joint Seals Joint Sealants Expansion Control
Joint Protection
08 OPENINGS 081 Doors & Frames 08.1100 08.1400 Metal Doors & Frames Wood Doors
07 THERMAL & MOISTURE PROTECTION 071 072 073 074 075 Damproofing & Waterproofing Thermal Protect & Weather Barriers Steep Slope Roofing Roofing & Siding Panels Membrane Roofing 07.5100 07.5200 Built-Up Bitum Rfng Mod Bitum Memb Rfng
Specialty Doors & Frames 08.3100 08.3200 08.3300 08.3400 08.3500 08.3600 08.3700 Access Doors & Panels Sliding Glass Doors Coiling Doors & Grilles Specialty Function Doors Folding Doors & Grilles Panel Doors Traffic Doors
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Entrances, Storefronts, Curtain Walls 08.4100 08.4400 Entrances & Storefronts Curtain Wall & Glazed Assemblies
085
Wall Finishes 09.7200 09.7300 09.7400 09.7500 09.7600 09.7700 Wall Coverings Wall Carpeting Flexible Wood Sheets Stone Facing Plastic Blocks Special Wall Surfacing Acoustic Insulation Acoustic Finishes Acoustic Room Components & Panels
Roof Windows & Skylights Hardware Glazing Louvers & Vents 098 Plaster Assemblies Gyp Board Assemblies Plaster & Gypsum Board Assemblies 09.2113 09.2116
09 FINISHES
093 095
Tiling Ceilings 09.5100 09.5300 09.5400 09.5600 Acoustic Ceilings Acoustic Clng Susp Sys Specialty Ceilings Textured Ceilings 099
10 SPECIALTIES 101 Information Specialties 10.1100 10.1200 Visual Display Surfaces Display Cases
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 ONLY SELECT THE ITEMS THAT YOU HAVE ABILITY TO SELF-PERFORM WITH OWN FORCES 10.1300 10.1400 10.1700 10.1800 102 10.2113 10.2116 10.2123 10.2200 10.2500 10.2600 10.2800 Directories Signage Telephone Specialties Information Kiosks Toilet Compartments Shower & Dressing Compartments Cubicles Partitions Service Walls Wall & Door Protection Toilet, Bath, & Laundry Accessories 103 104 Fireplaces & Stoves Safety Specialties 10.2810 Emergency Access & Info Cabinets 10.2820 10.2830 105 Emergency Aid Specialties Fire Protection Specialties 1131 1133 1140 1152 1153 1161 1166 108 10.7500 10.7300 10.7400 107 Exterior Specialties 10.7100 Exterior Protection (Sun Control or Storm Panels) Protective Covers, Awnings, & Canopies Manufact Ext Specialties (Ext Clocks, Cupolas, Spires, Steeples, Weathervanes, & Window Wells) Flagpoles
Interior Specialties
11 EQUIPMENT 1112 1113 1116 1119 1123 Parking Control Equipment Loading Dock Equipment Vault Equipment Detention Equipment Commercial Laundry & Dry Cleaning Equipment Residential Appliances Retractable Stairs Foodservice Equipment Audio-Visual Equipment Laboratory Equipment Theater & Stage Equipment Athletic Equipment
Storage Specialties 10.5100 10.5500 10.5600 10.5700 Lockers Postal Specialties Storage Assemblies Wardrobe / Closet Specialties
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 ONLY SELECT THE ITEMS THAT YOU HAVE ABILITY TO SELF-PERFORM WITH OWN FORCES 1168 1182 1190 Play Field Equip & Structures Solid Waste Handling Equipment Other Equip: 1313 1318 1321 1327 1331 1332 1333 Aquariums Ice Rinks Controlled Environment Rooms Vaults Fabric Structures Space Frames Geodesic Structures
12 FURNISHINGS 122 123 Window Treatments Casework & Countertops 12.3000 12.3600 12.3653 124 Casework Countertops Laboratory Countertops
14 CONVEYING SYSTEMS 141 142 143 144 147 148 149 Dumbwaiters Elevators Escalators & Moving Walks Lifts Turntables Scaffolding Other Conveying Equipment 1491 1492 Facility Chutes Pneumatic Tube Systems
Furnishings & Accessories 12.4633 12.4643 12.4813 Waste Receptacles Monitor Support Systems Entrance Floor Mats & Frames 12.4819 Entrance Floor Grilles
126
Multiple Seating 12.6100 12.6313 12.6613 12.6700 Fixed Audience Seating Stadium Bench Seating Telescoping Bleachers Pews & Benches
21 FIRE SUPPRESSION 22 PLUMBING 23 HVAC 25 INTEGRATED AUTOMATION 26 ELECTRICAL 27 COMMUNICATION 28 ELECTRONIC SAFETY & SECURITY
129
Other Furnishings 12.9200 12.9300 Int Planters & Plantings Site Furnishings
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 ONLY SELECT THE ITEMS THAT YOU HAVE ABILITY TO SELF-PERFORM WITH OWN FORCES 31 EARTHWORK 31.2319 31.2336 31.2513 31.3200 31.6200 31.6300 Dewatering Trucking Silt Fencing Soil Stabilization Driven Piles Bored / Drilled Piles & Caissons 31.7300 Tunneling 32.3100 32.3200 32.8400 32.9000 33 UTILITIES 34 TRANSPORTATION 35 WATERWAY & MARINE CONTRUCTION 40 PROCESS INTEGRATION 41 MATERIAL PROCESSING & HANDLING EQUIP 42 PROCESS HEATING, COOLING, & DRYING EQUIP 43 PROCESS GAS & LIQUID HANDLING, PURIFICATION & STORAGE EQUIPMENT 44 POLLUTION CONTROL EQUIPMENT 45 INDUSTRY SPECIFIC MANUFACTURING EQUIP 48 ELECTRICAL POWER GENERATION Fences & Gates Retaining Walls Landscape Irrigation Landscaping (Exterior)
32 EXTERIOR IMPROVEMENTS 32.1216 32.1313 32.1400 32.1613 32.1800 Asphalt Paving Concrete Paving Unit Paving Concrete Curbs & Gutters Athletic & Recreational Surfacing
VERIFICATION I ______________________________________________________, being duly sworn, an employee and Officer of _______________________________________________________, depose and say: as of the execution date of this Subcontractor Qualification Questionnaire, the information contained herein is accurate and complete.
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W91238-13-R-0036 | Satellite Communications Earth Terminal Station Facility, Camp Roberts, CA | DM13057
Exhibit B
Subcontractor Qualification Questionnaire
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 Business Classifications: Descriptions and Definitions Business classifications indicated on the Subcontractor Qualification Questionnaire shall be based on the Primary NAICS Code indicated and the definitions herewith. For companies that use more than one NAICS code, the Primary NAICS code shall represent the scope of work most often provided. The definitions provided herewith are not guaranteed and shall not waive the certifying company's responsibility to review and understand the definitions pursuant to the Federal Acquisition Regulation (FAR) part 19.7 or 52.219-8 (http://www.acquisition.gov/far/). Where the below definitions conflict with those provided in the FAR, the FAR definition shall govern. If you have difficulty ascertaining your size status, refer to SBA's website at http://www.sba.gov/content/table-small-business-size-standards or contact your local SBA office. Small Business Administration (SBA) Classifications: Refer to definitions provided on the Small Business Self-Certification Form for the following SBA classifications: SB, SDB, SDB8(a), WOSB, HUBZoneSB, VOSB, and SD-VOSB.
Other Business Classifications: ANC: "Alaskan Native Corporation". Refer to definition provided on the Small Business Self-Certification Form. IEE: Indian Economic Enterprise is any Indian-owned (as defined by the Secretary of the Interior) commercial, industrial, or business activity established or organized for the purpose of profit: Provided, that such Indian ownership shall constitute not less than 51 per centum of the enterprise. TO: "Tribally Owned". Refer to definition provided on the Small Business Self-Certification Form. DBE: "Disadvantaged Business Enterprise" is similar to the definition of MBE, but Small Business WBEs may also qualify. DBE certification is controlled by varying agencies across the United States, but is predominantly used by state and Federal Departments of Transportation as well as local airport authorities. Official DBE certification is required and certification requirements may vary between agencies. MBE: "Minority Business Enterprise" is an independent business concern that is at least 51% owned and controlled by one or more socially and economically disadvantaged individuals who are U.S. citizens or Legal Resident Aliens, whose business formation and principal place of business are in the US or its territories, whereby the individual minority applicants have technical expertise and experience relating to specific products and services provided by the firm as well as the authority to make day-to-day and long term business decisions for the firm. MBE certification is controlled by varying agencies across the United States, but is predominantly used by city and county agencies. Official MBE certification is required and certification requirements may vary between agencies. To obtain MBE certification, most agencies dictate caps on personal net worth for each minority applicant as well as size standards for the business.
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Exhibit B
Subcontractor Qualification Questionnaire
929 West Adams Street, Chicago, IL 60607 Phone: 312.563.5400 Fax: 312.429.0651 WBE: "Women's Business Enterprise" is an independent business concern that is at least 51% owned and controlled by one or more women who are U.S. citizens or Legal Resident Aliens, whose business formation and principal place of business are in the US or its territories, where the individual women applicants have technical expertise and experience relating to specific products and services provided by the firm as well as the authority to make day-to-day and long term business decisions for the firm. WBE certification is controlled by varying agencies across the United States, but is predominantly used by city and county agencies. Official WBE certification is required and certification requirements may vary between agencies. To obtain WBE certification, some agencies may also dictate caps on personal net worth for each woman applicant as well as size standards for the business. SBE: Small Business Enterprise is similar to the definition of SB Small Business except that SB is self-certifying and SBE requires an official certification. VOB: "Veteran Owned Business" is similar to "Veteran Owned Small Business" (VOSB), except there is no size standard. DVBE: "Disabled Veteran Business Enterprise" (also referred to as SDVBE Service Disabled Veteran Business Enterprise) is similar to "Service-Disabled Veteran-Owned Small Business" (SD-VOSB), except there is no size standard. A DVBE automatically qualifies as a VOB. HBCU/MI: Means "Historically Black Colleges and Universities/Minority Institution". Refer to definition provided on the Small Business Self-Certification Form. NHO: "Native Hawaiian Organizations" means any community service organization serving Native Hawaiians in the State of Hawaii which is a not-for-profit organization chartered by the State of Hawaii, is controlled by Native Hawaiians, and whose business activities will principally benefit such Native Hawaiians. AbilityOne: Refer to definition provided on the Small Business Self-Certification Form.
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