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OSHA Confined Space <br />Training Certification <br />(Name of holder, expiration date) <br />License Information <br />(Name of holder, license type, <br />number) <br />By signing and submitting this application, Uwe agree to follow all City of South Bend Prevailing <br />Specifications and Special Provisions (enclosed in the Sewer Insurance Program Policy as Exhibit G) <br />By signing and submitting this application for pre -qualification, Uwe understand that as a Contractor under <br />the City Sewer Insurance Program, Uwe shall be directly and solely liable to a Homeowner for any damage <br />to any Homeowner's person or property caused by the Contractor's acts, conduct or omissions arising from <br />or within the scope of this Program. Uwe shall release and fully indemnify the City from any claim or cause <br />of action of any kind which Homeowner may make against the City for any act, conduct or omission by the <br />Contractor under this Program. Indemnification includes but is not limited to Contractor's payment of any <br />legal fees or legal expense incurred by the City in defending such Homeowner claim. <br />Signature <br />Date <br />Signature <br />Title <br />Date <br />14 <br />