Corporation

x

, .

DOT Form 420-010Revised 01/2020

Standard Questionnaireand

Financial Statement

360-705-7837

prequal@wsdot.wa.gov

NOTE:

prequal@wsdot.wa.gov

Street Address State Zip Code

State Zip Code

Fax

Yes No

DOT Form 420-010Revised 01/2020

Standard QuestionnairePreparation of Standard Questionnaire

Standard QuestionnaireNOTE:

Contract * Class Completion Date

Prime or

3a.

3c.

3d.

DOT Form 420-010Revised 01/2020

Contract Amount $

* Class of Work

Scheduled Completion Date

Prime or Sub Title / Contract No.

Contracting Agency and Contact Name, Phone Number and Email (Email for contacts is required for processing of the application.)

Attach additional sheet(s) if more space is needed

DOT Form 420-010Revised 01/2020

Class Number Class Description Project Example (From Page 3)

1 Clearing, Grubbing, Grading, and Drainage (Scrapers or trucks, graders, compaction equipment, dozers, backhoes, frontloaders.)

2 Production and placing of crushed materials (Crushing plant, haul vehicles, motor patrol, compaction equipment)

3 Bituminous Surface Treatment (Distributor, chip, spreader, rollers, trucks, graders, compaction equipment, dozers, backhoes, frontloaders.

4 Asphalt Concrete Paving (Asphalt plant, asphalt pavers, rollers, trucks)

5 Cement Concrete Paving. (Slipform paving machines, concrete plant, trucks)

6 Bridges and Structures (Cranes, general building tools)

7 Buildings (General building tools)

8 Painting - Structural (Painting equipment, scaffolds, ladders etc.)

9

DOT Form 420-010Revised 01/2020

Individual’s NameYears of

Construction Experience

Dollar Value and Class(es) of Work

Position Held

Yes No

DOT Form 420-010Revised 01/2020

Preparation of Financial Statement

A compiled Financial Statement is not acceptable.

Example Date of Financial Statement

June 30 Following Year

Financial Statement

Year

3. Additional Financial Resource(s)

Source Dollar Amount

Yes No

Yes No

Yes No

Statement of Financial Ability

Financial Statement

DOT Form 420-010Revised 01/2020

Type of Organization Joint Venture Coporation LLC

Corporation Co-Partnership or Joint Venture

Status General Limitied Assoc.

Yes No

Yes No

Non-Collusion

Yes No

Yes No

Yes No

Yes No

Authorized Signatures

Name Title Signature

DOT Form 420-010Revised 01/2020

Sole Proprietorship

Co-Partnership

Corporation

Joint Venture

statement.

Name of Firm

Signature Signature

Signature Signature

residing at

Corporate Seal if available Notary Seal

Date

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

Page C1

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.

Page C2

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.