Subcontractor Qualification Statement

Subcontractor Qualification Statement Trade: Legal Name of Firm: Address: No. & Street City State Zip Mailing Address: If different from above address E-mail address: Telephone #: Fax #: Website: Type of Business: (Individual, Partnership, Corporation) State Incorporated In: Years in Business: Federal Tax ID #: Contractor License #: State: Expiration Date: Name(s) of Principal Owner(s) Annual Sales Volume for 3 years:,, Number of Employees: Union Affiliation(s): Contractor License #: Class: State: Expiration Date: Square Footage Scope of Work Capabilities: Subcontract Amount Limitations: Names and Titles of Persons Authorized to Execute Contracts and sign Lien Waivers: Name: Title: Name: Title: Name: Title: 985 Industrial Road, Suite 101 San Carlos, CA 94070 Phone 650.637.5407 Fax 650.508.9102 www.rylkobuilders.com License No. 955155 Building with Integrity, Vision, Excellence, and Commitment

Provide Bank References: Name of Bank: Address: City/State/Zip: Contact Person: Telephone No.: Please submit Evidence of Insurance Certificate meeting attached RBI conditions of insurance requirements. Insurance Company: Name Address Agent or Broker Name Address Telephone No. Experience Modification Rate: Does your company have a formal Illness/Injury Prevention Program and a written Safety Program: Yes No Bonding Company: Name Address Telephone No. Present Bonding Capacity: $ Bonding Agent: Name Address Telephone No. Has your company ever failed to complete any work awarded to you? If so, please note when, where and supporting circumstances: Has your firm ever filed for bankruptcy? If so when: Within the last five years, has any officer or partner of your company ever been an officer or part of another organization when it failed to complete a construction subcontract? If so, provide an explanation: 985 Industrial Road, Suite 101 San Carlos, CA 94070 Phone 650.637.5407 Fax 650.508.9102 www.rylkobuilders.com License No. 955155 Building with Integrity, Vision, Excellence, and Commitment

Client References: Please provide a list of at least five (5) client references and five (5) General Contractor references that we may contact regarding your work. These references should be for similar projects: Provide requested information on a separate sheet. Client references example: Company Name: Contact Name: Address: City/State/Zip: Telephone No: Email: General Contractor references example: Company Name: Contact Name: Address: City/State/Zip: Telephone No: Email: Project(s) Name: Name of person completing this form: Print Name Signature of Principal or Company Officer: Print Name Title: Signature:_ 985 Industrial Road, Suite 101 San Carlos, CA 94070 Phone 650.637.5407 Fax 650.508.9102 www.rylkobuilders.com License No. 955155 Building with Integrity, Vision, Excellence, and Commitment

Subcontract Number: RBI Project Number: Project Name: Project Address: City, State, Zip Code Attached to and replacing Section 16 of the Subcontract Agreement between BUILDERS, INC. (Certificate Holder) and (subcontractor s name). Immediately send a copy of this information to your insurance broker or agent for compliance. 1.0 Certificates of Insurance. Prior to Work commencing under this Subcontract, Subcontractor shall furnish to RYLKO BUILDERS, INC. Certificates of Insurance and all required policy endorsements for Additional Insured and Waiver of Subrogation, as evidence of insurance required herein. The Certificates of Insurance shall provide that there will be no cancellation or reduction of coverage without thirty (30) days (ten (10) days for non-payment of premium) prior written notice to. The words endeavor to and but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives shall be crossed out on the certificate. Evidence the Project Name, Address and s Job Number shall be listed in the Description section of the Certificate and on all project specific Certificates and Endorsements. 2.0 Mandatory Insurance Coverage. Subcontractor shall, at its own expense, maintain in effect at all times during the performance of the Work under this Subcontract Agreement not less than the following coverage and limits of insurance: 2.1 Workers Compensation and Employer s Liability. As required by any applicable law or regulation. Employer s Liability Insurance shall be provided in the amounts not less than: Subcontractor s Name Initials / Date $1,000,000 Each Accident for Bodily Injury $1,000,000 Each Employee for Bodily Injury by Disease $1,000,000 Policy Limit for Bodily Injury by Disease If there is an exposure of injury to Subcontractor s employees under the U.S. Longshoremen s and Harbor Workers Compensation Act, the Jones Act or under laws, regulations or statutes applicable to maritime employees, coverage shall be included for such injuries or claims. 2.2 Commercial General Liability Occurrence Form. Covering all operations by or on behalf of Subcontractor, providing insurance for bodily injury liability and property damage liability for at least the minimum limits of liability indicated below and including coverage for: (1) Premises and Operations; (2) Independent Contractor Liability (including Contingent Liability); (3) Products and Completed Operations; (4) Contractual Liability insuring obligations assumed in this subcontract; (5) Broad-Form Property Damage (including Completed Operations); (6) Explosion, Collapse and Underground Hazards (including Subsidence); (7) Personal and Advertising Injury Liability; (8) Separation of Insureds Clause. Policy shall NOT be issued under a claims-made policy form or a modified occurrence policy form. Any self-insured retention or deductible greater than $25,000 must be declared to at time of bid and approved by in writing. Coverage shall be maintained continuously for five (5) years (or more up to ten (10) years, if specifically requested in writing by or Owner) following Project completion. Page 1 of 4

2.2.1 Minimum Limits of Liability. $1,000,000 Each Occurrence (combined single limit for bodily injury and property damage) $2,000,000 Products-Completed Operations Aggregate $1,000,000 Personal Injury Liability $2,000,000 General Aggregate, per Project 2.2.2 Per Project General Aggregate. The policy must have an endorsement providing that the general aggregate limit applies separately to this project. If a per-project aggregate is not provided, the total limit of liability shall be $5,000,000. This limit can be satisfied by either providing a primary policy or in combination with an excess liability policy. 2.3 Automobile Liability. Covering any auto (owned, hired and non-owned) in limits of liability not less than $1,000,000 combined single limit each accident for bodily injury and property damage. If Subcontractor s Auto Liability insurance is provided by a Commercial General Liability policy, then Subcontractor s General Liability policy shall include coverage for automobile contractual liability. 2.4 Umbrella/Excess Liability. Where Umbrella and/or Excess policies are used to satisfy increasing limits of liability, such policies must not reduce nor restrict coverage otherwise required for General or Automobile Liability coverage. 3.0 Other Required Insurance Coverage where Exposure Exists. The following insurance shall be required by the Subcontractor and Sub-subcontractors to the extent that such activities exist in the performance of Work under this Subcontract and are not covered under the General Liability policy. 3.1 Work Near Railroads. If Subcontractor (including any lower tier subcontractor) performs any work or conducts any operations within fifty feet of any railroad (including any light rail, fixed rail or other rail system), Subcontractor shall obtain an endorsement of its Commercial General Liability Policy to delete any exclusion, including the Contractual Liability exclusion, for work performed within fifty feet of a railroad. A copy of such endorsement shall be provided to prior to any work or operations by Subcontractor within fifty feet of any railroad. 3.2 Aircraft Liability. If Subcontractor or their subcontractors use any owned, leased, chartered or hired aircraft of any type (including helicopters) in the performance of this Subcontract, they shall maintain aircraft liability insurance in an amount of not less than $10,000,000 per occurrence including Passenger Liability. 3.3 Crane Services Liability. If Subcontractor s Work includes providing Crane Services, then the Commercial General Liability shall be amended to apply with minimum limits of liability to insure against bodily injury and property damage arising from such crane operations. The policy shall include coverage for Rigger s Liability and shall not exclude coverage for damage to property being lifted. $10,000,000 Each Occurrence (combined single limit for bodily injury and property damage) $10,000,000 Personal Injury $10,000,000 Products-Completed Operations Aggregate $10,000,000 General Aggregate, per Project Subcontractor s coverage for Crane Services may be provided either by Subcontractor s own policy(ies), or by the policy(ies) of a lower tier contractor providing such Crane Services for Subcontractor. The policy shall include a Per Project General Aggregate pursuant to Section 2.2.2. 3.4 Professional Liability. If Subcontractor or any Sub-subcontractor of any tier is providing any professional services, including, but not limited to, design, engineering or design/build services on the Project, minimum limits of $1,000,000 per Claim / Aggregate shall apply. If coverage is issued on a claims-made form, such coverage shall apply with a retroactive date to reflect the date in which professional services commenced under this Subcontract. Coverage shall also be maintained continuously for a minimum of five (5) years (or more up to ten (10) years, if specifically requested in writing by or Owner) following Project completion or included with an Extended Reporting Period for the equivalent minimum number of years requested. However, if or the Owner elects to purchase a project design policy, Subcontractor s policy will be endorsed to provide coverage once the design policy has been exhausted. Page 2 of 4

3.5 Contractor s Pollution Liability. 3.5.1 Hazardous Materials Remediation. If Subcontractor s or its Sub-subcontractor s Work includes remediating hazardous materials, including but not limited to, asbestos containing materials, silica, lead, PCBs, contaminated soil etc., minimum limits of liability of $2,000,000 per claim or per occurrence, and not less than $2,000,000 aggregate shall apply to cover liability for bodily injury, property damage or clean-up costs resulting from pollution conditions. 3.5.2 Mold Coverage. Subcontractor s Pollution Liability policy to include coverage for mold or fungus with limits of not less than $1,000,000 if any of Subcontractor s Work includes or directly or indirectly impacts any of the work scopes as defined in this subsection 3.5.2 3.5.2.1 All work which could in any way contribute to or cause moisture to be introduced into the interior of the building, either by construction, sealing or penetrating any portion of the building s exterior envelope or releasing moisture within the building, are required to have the above coverage for mold insurance. These include but not limited to the following: 3.5.2.1.1 Exterior Envelope (envelope areas are defined as including all above and below ground exteriors of the building or facility, be they vertical, horizontal or angled surfaces) related work may include but not limited to scopes such as masonry, cast-in-place concrete (including slab on grade, elevator or other pits or shafts), pre-cast concrete, gunite, shortcrete, plaster, drywall (exterior gypsum sheathing and building paper), marble or stone facades, EIFS, metal panel, glass & glazing, exterior insulating, roofing, skylights, louvers, exterior doors (all types), sheet metal and flashing, expansion joints, any form of waterproofing and/or damp proofing, caulking and sealants, etc. 3.5.2.1.2 All systems which directly or indirectly involve water retention, generation or conveying work within or in close proximity to the building such as plumbing, HVAC, fire sprinkler and process piping and the controls of their wet systems, below slab mechanical, sump pits, tanks, site utilities and/or irrigation systems (near, attaching to or penetrating the building), etc. 3.5.2.1.3 All scopes that may penetrate or seal penetrations of the exterior envelopes such as equipment roof supports, satellite dishes, photovoltaic panels, handrails, trellises, miscellaneous or ornamental metal, signage and subcontractors who seal their own exterior penetrations. 3.5.3 If coverage required hereunder Section 3.5 is issued on a claims-made form, such coverage shall apply with a retroactive date to reflect the date in which Work commenced under this Subcontract. Coverage shall also be maintained continuously for a minimum of five (5) years (or more up to ten (10) years, if specifically requested in writing by or Owner) following Project completion or included with an Extended Reporting Period for the equivalent minimum number of years requested. 3.6 Automobile Pollution Liability. If Subcontractor or its Sub-subcontractors of any tier haul hazardous waste, Automobile Liability limits of at least $2,000,000 combined single limit each accident for Bodily Injury and Property Damage applicable to all hazardous waste hauling vehicles and include a MCS-90 endorsement. In lieu of this coverage, shall accept a Transportation Coverage Endorsement extension from Subcontractor or their subcontractor s respective Contractor s Pollution Liability policy to cover this requirement, but only to the extent that such endorsement has been attached to the Certificate. 4.0 Acceptance by. The required insurance shall be subject to the approval of RYLKO BUILDERS, INC.. Such insurance shall be maintained under forms of policies and from companies satisfactory to RYLKO BUILDERS, INC. and Owner. The insurance companies must also have an A.M. Best s Rating of at least A- and a financial size of Class VII or better in the latest edition of Best s Insurance Reports (except for the State Fund for Workers Compensation coverage). Copies of policies shall be provided when requested. Any acceptance of Certificates of Insurance by RYLKO BUILDERS, INC., or failure of Subcontractor to provide Certificates of Insurance, shall in no way limit or relieve the Subcontractor of its duties and responsibilities in this Agreement. If higher limits or other forms of insurance are required in the Subcontract Documents, Subcontractor will comply with such requirements. Page 3 of 4

5.0 Additional Insured Endorsement and Primary Insurance Clause. The General Liability insurance policy shall include a provision, or endorsement, at least as broad as the CG 20 10 07 04, in combination with CG 20 37 07 04 (or Form B CG 20 10 11 85 by itself), as published by Insurance Services Offices (ISO), naming as additional insured, the Owner, and any person or organization for whom Subcontractor is required by written contract/purchase order or permit to name. As to all other liability insurance polices, with exception to Professional Liability, similar provisions or endorsements for Additional Insured shall be included with Certificates of Insurance. Such endorsement(s) shall also provide that insurance is primary with respect to the interest of all additional insureds and that any other insurance maintained by all additional insureds is excess and not contributing insurance with the insurance requirement(s) hereunder. Samples of Policy Endorsements are attached at the end of this Attachment. 6.0 Waiver of Subrogation. All insurance coverage evidenced herein shall include clauses providing that each insurer shall waive all of its rights of recovery by subrogation against together with Additional Insured parties. Where permitted by law, Subcontractor shall require similar written express waivers and insurance clauses from each of its Subcontractors of every tier. Samples of Policy Endorsements are attached at the end of this Attachment. 7.0 Insurance Requirements for Sub-subcontractors. The Subcontractor shall ensure that their Sub-subcontractors of any tier shall procure and maintain insurance in like form and amounts including the Additional Insured and Waiver of Subrogation requirements. Copies of the Certificates and Endorsements must be provided prior to the sub-subcontractors entering the site. 8.0 Property Insurance. and Subcontractor waive all rights against each other and against all other subcontractors and Owner for loss or damage to the extent reimbursed by Builder s Risk or any other property or equipment insurance applicable to the Work, except such rights as they may have to the proceeds of such insurance. If the policies of insurance referred to in this Section require an endorsement or consent of the insurance company to provide for continued coverage where there is a Waiver of Subrogation, the owners of such policies will cause them to be so endorsed or obtain such consent. Where Builder s Risk insurance purchased by Owner or contains deductibles, Subcontractor shall be responsible (or such deductible applicable to damage to Subcontractor s Work and/or damage to other work caused by Subcontractor). Where Builder s Risk insurance is not purchased by Owner or, Subcontractor shall be fully responsible for all loss or damage to its Work. In the event of a loss insured under Builder s Risk insurance provided by or Owner and such insurance provides coverage for loss or damage to Subcontractor s Work, Subcontractor shall be bound by any adjustment which shall be made between or Owner and the insurance company or companies. Loss, if any, shall be made payable to and/or Owner, as their interest may appear, for the account of whom it may concern. shall not be responsible for any loss or damage to Subcontractor s Work, however caused, until final acceptance by and Owner. shall not be responsible for loss or damage to materials, tools, equipment or other personal property owned, rented or used by Subcontractor or anyone employed by Subcontractor in the performance of the Work, however caused. Insurance for any loss or damage to Subcontractor s machinery, tools, equipment or other personal property owned by Subcontractor or anyone employed by it in the performance of the Work, shall be the responsibility of Subcontractor. Page 4 of 4