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Exhibit A: Lead Hazard Reduction Program Contractor Application <br />City of South Bend <br />Lead Hazard Reduction Program <br />Contractor Application <br />Company <br />Name: <br />Street <br />Address: LS e 0 i a i cm s( -- <br />City: &kMq &_�D State: Z& Zip Code: <br />Business <br />Owner's D r� <br />Name: l)AOAI –LQ l P)Onnil.Q Phone: .1—TilA <br />Email: <br />1. Is applicant a Licensed Indiana Abatement Contractor? 111/yes ❑ No <br />If yes, provide a copy of license. <br />2. Will the applicant have at least one licensed Lead Project Supervisor on-site? F(yes ❑ No <br />If yes, provide a copy of licenses of Lead Project Supervisor(s) and Lead Worker(s) for all employees or <br />subcontractors who will be performing lead abatement work. <br />3. Is applicant an EPA approved Renovation, Repair and Painting certified firm? I"Yes ❑ No <br />If yes, provide a copy of certification. <br />4. Does applicant have required Commercial General Liability Insurance? 19 Yes ❑ No <br />If yes, provide a copy of the Statement of Coverage. It must include a minimum coverage of per Person <br />in the amount of $50,000 and per Occurrence in the amount of $1,000,000. <br />5. Does applicant have Worker's Compensation Insurance? 12"Yes ❑ No <br />If yes, provide a copy of the Statement of Coverage. <br />6. Are you or any of your employees licensed to do electrical, heating or plumbing work in the City of <br />South Bend? ❑ Yes ❑ No (If yes, provide name and license information below): <br />Name: License Type: License Number: <br />