Corporation

x

, .

DOT Form 420-011Revised 01/2020

SupplementalQuestionnaire

Contract Ad & AwardDepartment of Transportation360-705-7837 / Fax: 360-705-6966Email: prequal@wsdot.wa.govWhen Application is complete, submit by email to prequal@wsdot.wa.gov Submission Date:

Name of Applicant or Firm (As registered with Washington State Secretary of State)

Street Address City State Zip Code

PO Box City State Zip Code

Telephone Fax Federal Employees (IRS) ID No.

Email for Bidding Opportunities

The above Applicant or Firm is:

A Parent Firm of:

A Subsidiary- Division of:

Under the provisions of RCW 39.04.155 the Washington State Department of Transportation maintains a Small Works Roster for soliciting competitive bids on projects estimated to cost less than $350,000. Please indicate if your company is interested in being placed on the Small Works Roster. Yes No

Supplemental Questionnaire

ownership, incorporation, etc., or when required by the department, shall submit a Supplemental Questionnaire.

statement of retained earnings, supporting schedules and notes, and the opinion of the independent auditor must accompany the

30, September 30, or December 31 as outlined in WAC 468-16-090.

DOT Form 420-011Revised 01/2020

If Yes, complete the following: Yes No

Additional Supervisory Personnel Employed

Individual’s NameYears of

Construction Experience of Work In What Capacity

Individual’s NameYears of

Construction Experience of Work In What Capacity

Total Tangible Assets Total Liabilities Net Worth

$ $ $

have a notarized letter to document the Allocation. Required information within the letter is: The dollar amount, Purpose of the Allocation, and a termination date for the Allocation. A Sample Parent Firm Allocation Form can be found at: http://www.wsdot.wa.gov/biz/contaa/prequal/default.htm

Yes No

supporting data for your proposed changes. (Supporting data needed is the Name of the Project, Contact Person, Company Name, Phone and Email) (Attach additional sheets if necessary) Inquiries will be sent to the contacts listed for the completed projects.

Additional Classes

DOT Form 420-011Revised 01/2020

CorporationIf a corporation, complete this section

Co-Partnership or Joint Venture

When Incorporated Date of Organization

President’s Name State whether General, Limited, or Association

Secretary’s Name State whether there is any limitation on duration of Co-

Treasurer’s Name

If Out-of-State Corporation, have you complied with Washington’s Yes No

Non-Collusion

Yes No

If Yes, attach separate sheet(s) to this form giving details involved, the names of the individuals and Yes No

If Yes, attach separate sheet(s) to this form giving details involved. Yes No

Yes No

Authorized SignaturesList the name and Title of those individuals in your organization who are authorized to execute proposals, contracts, bonds, and other documents and/or instruments on behalf of the organization.The Signature MUST appear next to name.

Name (Typed) Signature Title

DOT Form 420-011Revised 01/2020

Co-Partnershipin Fact.

Joint Venture Signatures of an authorized representative of each party to the joint venture. Corporate members of a

Corporation

State of

} SSCounty of

The undersigned, being duly sworn, deposes and says that the foregoing is a true statement of facts concerning the individual, corporation, co-partnership, or joint venture

agency named in the aforementioned Standard Questionnaire and Financial Statement is hereby authorized to supply the Washington State Transportation Commission or

its agent with any information necessary to verify this statement.

Name of Firm (As registered with Washington State Department of Licensing)

Authorized Signature Authorized Signature

Authorized Signature Authorized Signature

Sworn to before me this day of ,

Notary Public

Corporate Seal Notary Seal

Class 1

Class 2

Class 3

Class 4

Class 5

Class 6

Class 7

Class 8

Class 9

Class 10

Class 11

Class 12

Class 13

Clearing, Grubbing, Grading and DrainingRemoval of tree stumps, shrubs, modificationof the ground surface by cuts and fills,excavating of earth materials, the placement ofdrainage structures, and construction ofstructural earth walls.Production and Placing of CrushedMaterialsProduction and placing crushed surfacingmaterials and gravel.

Bituminous Surface TreatmentPlacing of crushed materials with asphalticapplication.

Asphalt Concrete PavingProduction and placing Asphalt Concrete PlantMix Pavement.

Cement Concrete PavingProduction and placing cement concretepavement.

Bridges and StructuresConstruction of bridges and other majorstructures of timber, steel, and concrete.

BuildingsConstruction of buildings and relatedstructures and major reconstruction andremodeling of such buildings.

PaintingPainting bridges, buildings, and relatedstructures.

Traffic SignalsInstallation of traffic signal and controlsystems.

Structural Tile CleaningCleaning tunnels, large buildings andstructures and storage tanks.

GuardrailConstruction of a rail secured to uprightsand erected as a barrier between, or besidelanes of a highway.Pavement Marking (Excluding Painting)Thermoplastic markings, stripes, bars, symbols,etc. Traffic buttons, lane markers, guide posts.

DemolitionRemoval of timber, steel, and concretestructures and obstructions.

Class 14 Drilling and BlastingControlled blasting of rock and obstructionsby means of explosives.

Class 16

Class 17

Class 18

Class 19

Class 20

Class 21

Class 22

Class 23

Class 24

Class 25

Class 27

Illumination and General ElectricHighway illumination, navigational lighting,wiring, junction boxes, conduit installation.

Cement Concrete Curb and GutterSidewalks, spillways, driveways, monumentcases and covers, right-of-way markers,traffic curbs, and gutters.

Asphalt Concrete Curb and GutterSidewalks, spillways, driveways, monumentcases and covers, right-of-way markers,traffic curbs, and gutters.

Riprap and Rock WallsMortar, rubble, and masonry walls; rockretaining walls, and placing of large brokenstone on earth surfaces for protection againstthe action of water.

Concrete Structures Except BridgesCast-in place median barrier, prestressing,post-tensioned structures, footings,prefabricated panels and walls, retainingwalls, and ramps, foundations, rock bolts, andconcrete slope protection.

Tunnels and Shaft ExcavationTunnel excavation, rock tunneling, and softbore tunneling.

PiledrivingDriving concrete, steel, and timber piles.

Concrete Surface FinishesArchitectural concrete surface finishes (fracturedfin, random board, exposed aggregate, etc.).Waterproofing concrete surfaces (clear orpigmented sealer.)FencingWire and metal fencing, glare screens.

Bridge Deck RepairBridge expansion joint repair andmodification, bridge deck resurfacing repair.

SigningSign structures and sign foundations,.

Class 28 Drilled Large Diameter Slurry ShaftsDrilled Shafts 4' diameter or larger and greaterthan 15' deep when excavation is performedutilizing the wet method and concrete isplaced by tremie methods under a slurry.

Class 29 Slurry Diaphragm and Cut-Off WallsSlurry excavation and the construction ofstructural concrete walls and slurry cut-offwalls.

Prequalification Work Classes

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Class 30 SurveyingHighway construction surveying.

Class 15 Sewers and Water MainsDraining, pipe jacking, water systems,pumping stations, storm drainage systems,sewer rehabilitation, sewage pumpingstations, pressurized lines.

Class 32

Class 33

Class 34

Class 35

Class 36

Class 37

Class 38

Class 39

Class 40

Class 41

Class 42

LandscapingLandscape irrigation, planting, sodding,seeding, fertilizing, mulching, herbicideapplication, insecticide application, weedcontrol, mowing, liming, soil binder, topsoil.

EngineeringWork other than surveying, includingengineering calculations, drawing and otherrelated work for highway construction.

Erosion ControlSeeding, fertilizing, mulching, slope protection,topsoil application, hydroseeding, soilstabilization, soil sampling.

Precast Median BarrierA concrete barrier that is cast and cured inother than its final position used to divide themedian of two adjacent highways ortemporarily placed to divert traffic inconstruction zones.

Earth Retention and AnchoringInstallation of permanent soil nails, soldierpiles, timber lagging and micropiles. Soldierpile tie-back anchor wall construction.

Impact Attenuatorsstallation of approved protective systemsfilled with sand, water, foam, or othersubstances which prevent errant vehicles fromimpacting roadside hazards.

Paint StripingPainting bars, letters, symbols, and striping.

Slope ProtectionThe installation of a zinc-coated steel wiremesh anchored by wire rope and reinforcedconcrete posts or anchor rods. Used fordampening the effects of rolling rocks ontothe highway. Slope scaling, horizontal drains,rock dowels, and rock bolts for slopestabilization.Gabion and Gabion ConstructionConstruction of walls made with containersof galvanized steel hexagonal wire mesh andfilled with stone.

Intelligent Transportation Systems (ITS)Traffic Sensors Systems, Highway AdvisoryRadios, Environmental Sensing Stations,Variable Message Signs, Non-Fiber OpticBased Closed Circuit Television and VideoSystems.

Electronics-Fiber Optic BasedCommunications SystemsDesign and installation of fiber optic basedcommunication systems.

Class 43 MechanicalPlumbing work and the installation of heatingor air conditioning units.

Class 44

Class 45

Class 46

Class 47

Class 48

Class 49

Class 50

Class 51

Class 52

Class 53

Class 54

Class 55

Asbestos AbatementsAsbestos Abatement (L & I Certified Workers).

Hazardous Waste RemovalThe containment, cleanup, and disposal of toxicmaterials. Companies seeking this classificationshall have full-time personnel with currenthazardous waste training (certification).

Concrete RestorationPavement subseal, cement concrete repair,epoxy coatings, epoxy repair, masonry repair,masonry cleaning, special coatings, epoxyinjection, gunite, shotcrete grouting,pavement jacking, gunite repair, and pressuregrouting.

Concrete Sawing, Coring, and GroovingConcrete sawing, concrete planing, grinding,grooving, bump grinding, joint repair,concrete coring and rumble strips.

DredgingExcavating underwater materials.

Marine WorkUnderwater surveillance, testing, repair,subaquatic construction, anchors, and cablereplacement, floating concrete pontoonrepairs and modifications, disassembly andassembly of floating concrete pontoons.

Ground ModificationPressure Grouting, blast densification, stonecolumn, jet grouting, compaction, dynamiccompaction, soil mixing, gravel drain.

Well DrillingDrilling wells, installing pipe casing andpumping stations.

Sewage DisposalHauling and disposing liquid and solidwastes.

Traffic ControlProviding piloted traffic control, trafficcontrol labor, and maintenance and protectionof traffic.

Railroad ConstructionConstruction of railroad subgrade, placing ofballast, ties, and track and other items relatedto railroad work.

Steel FabricationWelding of steel members, heat straighteningsteel.

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Class 31 Water Distribution and IrrigationIrrigation systems and heavy duty waterdistribution.

Class 56 Street CleaningStreet sweeping with self-propelled sweepingequipment.

Class 57 Materials TransportingTruck hauling.

Class 58 Sand Blasting and Steam CleaningSteam cleaning, sand blasting, shot blasting,and water blasting.