36C26119B0020-008.docx

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Correct Pedestrian Sidewalk, Install artificial turf, Retaining Wall, and doors for Building 650 VA Northern California Healthcare System in Mather, CA
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36C26119B0020
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36C26119B0020 CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL.docx

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CONTRACTOR CERTIFICATION REGARDING SAFETY AND ENVIRONMENTAL

Contractor Certification Regarding Project: 612A4-19-011

2016
2017
2018
2019

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful disqualifies the contractor.)

Company’s Current Insurance Experience Modification Rate (EMR) = _____________ (Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature: ______________________________________________

Typed Name: ______________________________________________________

Title: ______________________________________________________

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