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OSHA Competent Person <br />Certification <br />(Name ofholder• exphalion date) <br />OSHA Confined Space <br />Training Certification <br />(Name ofholder• expiration date) <br />nn\\\\ <br />n t1Ci.C1'�C� <br />License Information <br />CL" <br />cn <br />(Name ofholder, license type, <br />number) <br />—Tv�&t®X <br />_ P1un,btn�✓ <br />Con1��k�' <br />`TylQc M, <br />�rc3.m2. PC\\�ppD`$D <br />Equipment On Hand <br />(Provide proof of ownership and <br />list of equipment awned by <br />company for use in determination <br />ofpre-qualification) <br />By signing and submitting this application, Uwe agree to <br />follow all City <br />of South <br />Bend Prevailing <br />Specifications and Special Provisions (enclosed in the Sewer <br />Insurance Program Policy as <br />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 le ex ease incurred by the <br />/jCity <br />�in defending such Homeowner claim. <br />Signatur Stgrmnre Signature <br />U-N�c <br />,a e, M. rca� <br />IS <br />