NC State Mann Hall Renovation Prequalification Form

NC State Mann Hall Renovation Prequalification Form

State of North Carolina Prequalification Form for First-Tier Subcontractors under CM at Risk
Pursuant to the statute, this form gathers information about the subcontractors seeking to qualify for the work and provides a general format for the prequalification criteria. Completing this questionnaire does not guarantee prequalification. Evaluation of the submittal shall be performed by the prequalification committee in accordance with GS 143-128.1, 143-135.8 and the State of NC Prequalification Policy.
Submitted to:

Contact Name: David Konopka

CM @ R Firm: Holder Construction Company

Address: 6210 Ardrey Kell Rd. Suite 400

City/State Zip Code: Charlotte, NC 28277

Phone Number: (803)-960-7970

E-mail Address: dkonopka@holder.com
Project:

Name of Project: North Carolina State University Mann Hall Renovation

Project Owner: North Carolina State University

Project Architect: Perkins & Will

Total Project Budget: $49,500,000

Anticipated Bid Date: March 2025

Project Start Date (Approx.): April 2025

Project Duration: Twenty-Four (24) Months
Project Description:

The “Mann Hall Renovation” project includes a complete interior abatement and demolition scope of the existing building on NC State's main campus, followed by construction of fully re-programmed classroom, academic and study spaces, fourth floor laboratory space, and an ESports arena.

To support the re-programming of this building, a new mechanical penthouse will be constructed to feed the 4th floor labs and a new elevator shaft will be installed (in addition to replacing the existing cab within a separate shaft). New electrical and mechanical equipment will be required, including replacing the existing transformer, and new fiber will be pulled from the existing manhole to support Esports needs.

NC State is currently under contract (as part of a separate Mann Hall related project) to replace the exterior glass and perform structural repairs, this scope is scheduled for completion August 2024.
If your firm is interested in prequalifying for this project/phase, please check the box for your trade(s). This is a preliminary list of Bid Packages and may change based on response and qualified bidders.*

01 - Earthwork / Site Utilities / Paving02 - Hardscape03 - Spray Fireproofing04 - Metal Panels / Louvers05 - Waterproofing / Caulking06 - Glass / Glazing (Exterior & Interior)07 - Misc. Steel / Ornamental Metals08 - Arch Woodwork / Millwork09 - Doors / Frames / Hardware10 - CFMF / Drywall / Ceilings11 - Carpet / Resilient Flooring12 - Ceramic Tile / Terrazzo13 - Paint / Wallcoverings14 - Overhead Doors15 - Lab Equipment16 - Specialties17 - Signage18 - Window Shades19 - Retractable Seating20 - General Trades (Package B)21 - Fire Protection22 - HVAC / Plumbing / Controls23 - Electrical24 - Fiber Reinforced Polymer25 - Controlled Environmental Room26 - Structured CablingOther
NOTICE TO ALL SUBCONTRACTORS: All sections of this Part A: Master Prequalification Form (Annual Submittal) must be provided ONCE A YEAR and filled out in its entirety. This form will expire on June 30th of each year and requires an update after July 1st. If any sections are not complete, then the prequal may be rejected. A separate Part B: Project Specific Supplement is required for each specific project. Part A and Part B will be evaluated together for the specific project. NOTE*** IF you have already completed a Part A: Master Prequalification (Annual Submittal) form for State projects since July 1st, 2024 - please let your trade contract know by sending via email and we can provide only Part B for completion / submission.
Part A - Master Prequalification Form (Annual Submittal)
1. Main Office Location & Company Contacts
Submitted By (Contacts Name)*

First NameLast Name
Company Name*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Fax Number
President/CEO*

First NameLast Name
CFO*

First NameLast Name
Primary Prequalification Contact Name*

First NameLast Name
Primary Prequalification Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Prequalification Contact Email Address*
example@example.com
Secondary Prequalification Contact Name

First NameLast Name
Secondary Prequalification Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Prequalification Contact Email Address
example@example.com
2. Business Type
Business Type (check one)*

CorporationPartnershipLimited Liability CompanySole ProprietorJoint Venture
Indicate your NC Statewide Uniform Certification (SWUC):*

MBEHBEAABEAIBEWBESDBDBENoneOther
Is your firm registered with the Department of the Secretary of State to conduct business in the State of North Carolina?*

YesNo
Is your firm owned or controlled by a parent or any other organization?*

YesNo
Describe Ownership if Yes:
Confirm that your company can demonstrate compliance with insurance coverages which meet or exceed the minimum requirements of State Construction Manual OC-15 Article 34. Workers Compensation Insurance as required by law and Employer's Liability Insurance Coverage with minimum limits of $100,000. Comprehensive general liability with minimum limits of $500,000 per occurrence for bodily injury and $100,000 per occurrence/$300,000 aggregate for property damage. Please attach a copy of your insurance certificate in the SUPPLEMENTAL INFORMATION section near the bottom of the form:*

YesNo
List all other names your firm has operated under for the past five (5) years (if applicable):
N/A if not applicable
3. Licensing Information

(Please provide all North Carolina professional licenses required for you to perform your services.)
NC License Type (check box)*

General ConstructionElectricalMechanicalPlumbingFire ProtectionOther

Rows	NC License Number/Name of Licensee	License Limit/Level
1
2
3
4

Has any license ever been denied or revoked?*

YesNo
If yes, please describe why:
4. Type of Scope Performed, Average project size (in terms of revenue), Largest project size (in terms of revenue)

List all Scopes of Work for which you would request prequalification review in the upcoming year (i.e. if you perform several different scopes such as Drywall/Ceilings, Paint, Flooring, etc., you would list as Scope #1, Scope #2, Scope #3)

For Each Scope of Work performed, list the following with values from the last 5 years. (Provide references upon request of the CM).*

Rows	Response:
Scope #1:
Percentage of Self Performed Work (%):
Average Project Size ($):
Largest Project Size ($)

For Each Scope of Work performed, list the following with values from the last 5 years. (Provide references upon request of the CM).

Rows	Response:
Scope #2:
Percentage of Self Performed Work (%):
Average Project Size ($):
Largest Project Size ($)

For Each Scope of Work performed, list the following with values from the last 5 years. (Provide references upon request of the CM).

Rows	Response:
Scope #3:
Percentage of Self Performed Work (%):
Average Project Size ($):
Largest Project Size ($)

List your two largest completed projects in the last 5 Years per scope. If submitting for multiple scopes, submit multiple sheets:*
List your two largest completed projects in the last 5 Years per scope. If submitting for multiple scopes, submit multiple sheets:*
5. Size of Company
List the annual dollar value billings the company has performed for each year over the last (5) five fiscal years.
What is your largest job completed?*
6. Current Workload
Number of active projects that your company is presently working on?*
What is the total dollar value of your projects under contract/in progress?*
Remaining revenue to earn (backlog) on active projects?*
7. Safety
List your company's Experience Modification Rate (EMR) for the past five (5) years:*
If any year of your EMR is over 1.00, please explain why:
N/A if not applicable
List your company's Total Recordable Incident Rate (TRIR) for the past five (5) years:*
List your company's Days Away Restricted or Transferred Rate (DART) for past five (5) years:*
List any OSHA fines and jobsite fatalities in the past (5) years. *
N/A if none
Please attach OSHA report describing the incident (if the above applies):

Cancelof
Does your company have a dedicated safety individual who inspects job sites on a regular basis? If yes, please provide name and contact information for this individual below:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Does your company have a Written Safety Program and Plan in compliance with current OSHA requirements for your scope of work (Y/N):*

YesNo
Does your company provide weekly training to your onsite employees? (Y/N):*

YesNo
Does your company perform weekly safety inspections on the jobsite? (Y/N):*

YesNo
8. Litigation, Claims, Criminal Convictions, & Administrative Actions
Has your company filed any claims against a CM at Risk or General Contractor within the last five years, whether resolved or still pending resolution?*

YesNo
If yes to the above question, please state the project name(s), year(s), and reason why:
Has your company been involved in any judgements, claims, arbitration or mediation proceedings, or suits within the last five years, whether resolved or still pending resolution?*

YesNo
If yes to the above question, please state the project name(s), year(s), case number and reason why:
Has your company ever failed to complete work awarded to it or has your company's work been supplemented by a CMAR or GC?*

YesNo
If yes to the above question, please state the project name(s), year(s), and reason why:
Have you ever paid liquidated damages on any project?*

YesNo
If yes to the above question, please state the project name(s), year(s), and reason why:
Has your bonding company had to take any of the following actions in the last 10 years: Project technical support, Payments to vendors, Supplement work on a contract, or complete a contract for your company?*

YesNo
If yes to the above question, please state the project name(s), year(s), and reason why:
Has a Bid Bond ever been collected upon on a project your company bid in the last 5 years?*

YesNo
If yes to the above question, please state the project name(s), year(s), and reason why:
Has your present company, its officers, owners or agents ever been convicted of charges relating to conflicts of interest, bribery, or bid-rigging?*

YesNo
If yes to the above question, please state the project name(s), year(s), and reason why:
Has your present company, its officers, owners, or agents ever been barred from bidding public work in North Carolina?*

YesNo
If yes to the above question, please state the project name(s), year(s), case number and reason why:
9. Historically Underutilized Business (HUB) Plan
Does your company currently have a documented plan for engaging subcontractor participation from Historically Underutilized Businesses?*

YesNo
If yes, please attach your company's HUB plan:

Cancelof
SUPPLEMENTAL INFORMATION

Required Supplementary Information that needs to be included at the same time the prequalification form is submitted.
1. Your most recent CPA audited or reviewed financial statements (Income Statement & Balance Sheet).*

Cancelof
2. Bonding Letter from your Surety Company listing single and aggregate bonding limits and what bonding capacity that is available.*

Please ensure letter is submitted on Surety letterhead, not on Broker letterhead.
Cancelof
3. A current Certificate of Insurance listing all insurance policies.*

Cancelof
4. Letter from Insurance carrier stating last five (5) years of EMR ratings.*

I.e. NCCI worksheets or equivalent from carrier
Cancelof
5. The last five (5) years of your OSHA 300 & 300A report.*

Please include summary log (300A) and detailed report (300) for each year
Cancelof
6. Copy of HUB Certification (if applicable)

Cancelof
7. Copy of Professional Licenses (if applicable)

Cancelof
Part B - Project Specific Supplement
1. Information
1.d Does your firm intend to Partner or Joint Venture with another Subcontractor for this Project:*

YesNo
1.d If yes, list the Companies involved and their applicable participating percentage (%):
2. Updated Company Information
2.a Please provide your Current Backlog ($ value)*
(unearned revenue as of date of this supplement)
2.b Confirm updated bonding letter (within last 30 calendar days) is attached above:*

YesNo
2.c Have you worked on a project with Holder Construction Company in the last five (5) years?*

YesNo
If yes, please provide list of all the Projects you've worked on with Holder Construction Company in the last five (5) years:

If no, N/A.
Cancelof
3. Project Specifics
3.a The assigned (or potentially assigned) Superintendent for this project shall be:*

First NameLast Name
Attach Resume:*

Cancelof
3.b Experience of the Superintendent on this specific type of project is:*

0-2 years3-4 years5-10 years10 or more years
3.c The assigned (or potentially assigned) Project Manager for this project shall be:*

First NameLast Name
Attach Resume:*

Cancelof
3.d Experience of the Project Manager on this specific type of project is:*

0-2 years3-4 years5-10 years10 or more years
3.e List three (3) current or recently completed projects of similar type which most closely reflects the size and complexity of the type of work being requested for the NCSU Mann Hall Renovation project within the last five (5) years:*
3.e List three (3) current or recently completed projects of similar type which most closely reflects the size and complexity of the type of work being requested for the NCSU Mann Hall Renovation project within the last five (5) years:*
3.e List three (3) current or recently completed projects of similar type which most closely reflects the size and complexity of the type of work being requested for the NCSU Mann Hall Renovation project within the last five (5) years:*
3.f.1 Provide total number of employees who fit the below title which are currently employed by your company:*
3.f.2 Percentage of self-performed work vs. subcontracting to lower tiers:*
Signature
By signing this document, you are acknowledging that all answers are true to the best of your knowledge. Any answers found to be falsified will bar you from being prequalified on this project.
Signature:*
Date:*
Name:*

First NameLast Name
Job Title:*
Should be Empty:

NC State Mann Hall Renovation Prequalification Form

Part A - Master Prequalification Form (Annual Submittal)

1. Main Office Location & Company Contacts

2. Business Type

3. Licensing Information

4. Type of Scope Performed, Average project size (in terms of revenue), Largest project size (in terms of revenue)

5. Size of Company

6. Current Workload

7. Safety

8. Litigation, Claims, Criminal Convictions, & Administrative Actions

9. Historically Underutilized Business (HUB) Plan

SUPPLEMENTAL INFORMATION

Part B - Project Specific Supplement

1. Information

2. Updated Company Information

3. Project Specifics

Signature