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OSHA Confined Space <br />Training Certification <br />(Name of holder. expiration date) <br />a - <br />License Information <br />(Name of holder. license type,�L- <br />uniher) <br />M . PC 1t �r 7c� 6b <br />Equipment On Hand <br />(Prorvdeproofofoumeishile and <br />list of equipment owned by <br />company.for use in determination <br />ofpre-qualification) <br />By sigiring 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, Uwes a e directly and solely liable to a Hoteowner for any damage <br />to any Homeowner's person or property caused by the Contractor's acts, conduct or ornissions 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-oHega expense incurred by the City in defending such Homeowner claim. <br />aStgn Sig! tore Signature <br />L'.L•b q R-�CAA> V, <br />rrdo Title Title <br />Orate .. Dale <br />Date <br />!tit <br />