9-Exhibits Contractors CAL OSHA Compliance.pdf
PDF 274 KB Posted
- Attached to
- DISTRICTWIDE HVAC UNIT REPLACEMENT State and local contract opportunity
- Solicitation number
- RFP 3863
- Issued by
- Riverside County, California
About this file
This document is a Cal/OSHA Compliance History and Standard Industry Code form from the Eastern Municipal Water District (EMWD) for Request for Proposal (RFP) #3863. The form requires contractors to disclose their safety and environmental compliance history by answering two key questions: 1) whether they have been cited by Cal/OSHA or any regulatory agency for safety or environmental violations in the past seven years, and 2) whether they have experienced a serious incident or fatality on a job site within the past ten years.
The form is designed to be submitted with a proposal package and includes spaces for detailed contractor information such as name, address, contact person, phone number, California state contractor's license number, and standard industry code. If a contractor answers "Yes" to either compliance question, they are required to provide specific details about the incident(s) and actions taken to prevent future violations. The document also includes a section for EMWD's Risk Management to review and approve the contractor's compliance history, with signature requirements for both the contractor's representative and EMWD's Risk Management team.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 1-CARB Contractor Mobile Source Form.pdf | ||
| 11-RFP 3863 Districtwide AC Unit Replacements.pdf | ||
| 12-Exhibits Timeframe To Complete.pdf | ||
| 13-Exhibits Submittal Check Off List.pdf | ||
| 4-Exhibits Business References.pdf | ||
| 5-Exhibits Subcontractor.pdf | ||
| 7-Exhibits Additions Deletions Exceptions.pdf | ||
| 10-Exhibits Qualifications Experience.pdf | ||
| 2-Exhibits Business Information.pdf | ||
| 3-Exhibits Pricding Page.pdf | ||
| 6-Exhibits Insurance Affidavit.pdf | ||
| 8-Exhibits Process To Complete Work.pdf |
Show all 12
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Text version
CONTRACTOR’S CAL/OSHA COMPLIANCE HISTORY AND SIC CODE
RFP #3863
(This document is to be submitted with the proposal package) (rev. 10/08/18)
Date:
Contractor’s Standard Industry Code:
Contractor’s Name:
California State Contractor’s License #:
Address:
Contact Person:
Phone No:
Please answer the following questions:
1. Has the contractor been cited by Cal/OSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven (7) years?
No Yes
2. Within the past ten (10) years has the contractor had a serious incident or fatality on a job site?
No Yes
* If yes to # 1 or #2, please provide information specific to the incident(s) and action(s) taken to ensure that there is not a repeat violation, or incident(s) (attach additional sheets if needed)
Contractor’s Representative signature:
FOR EMWD USE ONLY: Purchasing to forward to Risk Management for review
(Risk Management)
Approved: No Yes
Reviewed by (Risk Management)
(signature required)
| Date_11: |
| Contractors Standard Industry Code: |
| Contractors Name: |
| California State Contractors License: |
| Address_9: |
| Contact Person: |
| Phone No: |
| or environmental issues within the past seven 7 years: Off |
| Within the past ten 10 years has the contractor had a serious incident or fatality on a job site: Off |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow1: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow2: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow3: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow4: |
| Please answer the following questions 1 Has the contractor been cited by CalOSHA or any regulatory agency for a violation related to safety or environmental issues within the past seven 7 years No Yes 2 Within the past ten 10 years has the contractor had a serious incident or fatality on a job site No Yes If yes to 1 or 2 please provide information specific to the incidents and actions taken to ensure that there is not a repeat violation or incidents attach additional sheets if neededRow5: |
| Date_12: |
| FOR EMWD USE ONLY: |
| Date Risk Management: |
| Approved No: |
| Yes_5: |
| Reviewed by Risk Management: |
| signature required: |
| Signature2_es_:signer:signature: |
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