THE TOWN OF MIDLAND INVITATION TO SUBMIT PROPOSALS 2016 CANADA DAY FIREWORKS DISPLAY

Transcription

1 THE TOWN OF MIDLAND INVITATION TO SUBMIT PROPOSALS 2016 CANADA DAY FIREWORKS DISPLAY Proposals will be received by the Town of Midland for: Labour, Materials, and Insurance for the 2016 Canada Day Fireworks Display in the Town of Midland Proposal forms and specifications may be obtained at the Town of Midland municipal offices or alternatively on the municipal website Contractors may receive proposal forms/specifications by calling (705) ext 3206 or at All proposals must be received by Friday, April 21 st, 2016, 12:00 Noon to be considered. Proposals may be delivered or mailed to: Town of Midland, 575 Dominion Ave Midland, ONT L4R1R2 The Town of Midland reserves the right to reject any or all proposals or any part thereof at its discretion. The Town further reserves the right to negotiate directly with any and all contractors concerning any matter related to any proposal.

2 TABLE OF CONTENTS NOTICE TO BIDDERS... 3 PREFACE... 4 CONTRACTOR SELECTION PROCESS... 4 PROGRAM BUDGET... 4 FIREWORKS QUALITY... 4 METHOD OF SET-UP AND FIRING OF AERIAL SHELLS... 4 FIREWORK OPERATORS... 5 SPECIFICATIONS... 5 FIREWORKS... 5 FIREWORKS BUDGET... 6 SUPPLIES, EQUIPMENT and TRAINING... 6 DATE OF DISPLAY AND RAIN DATE... 6 FIREWORKS OPERATORS... 7 PROGRAM DISPLAY TIME CONDITIONS... 7 DELIVERY, INSPECTION, STORAGE, SET-UP, DISMANTLING AND UNEXPLODED SHELLS... 7 FIRING SITE AND SPECTATOR CONTROL... 8 INSURANCE... 8 HEALTH AND SAFETY.. 9 TOWN CONTACT 9 EVALUATION OF PROPOSALS... 9 WORKSHEET A WORKSHEET B WORKSHEET C PROPOSAL FORM

3 NOTICE TO BIDDERS Bids will be received by the Town of Midland on or before 12:00 Noon on: Friday, April 21 st, 2016 for: Labour, Materials, and Insurance for the 2016 Canada Day Fireworks Display in the Town of Midland Proposal forms and specifications may be obtained at the Town of Midland municipal office at 575 Dominion Ave, L4R 1R2, Midland or alternatively on the municipal website No proposal will be considered unless the proposal forms (included) are properly completed and enclosed in a sealed envelope, marked: "MIDLAND CANADA DAY FIREWORKS In addition, the Town of Midland (referred hereafter as the Town ) will not consider any proposal which has not been received prior to the published time, date and year of proposal opening (fax and transmittals will not be accepted). The Town reserves the right to reject any or all proposals, or any part thereof at its discretion, and to waive any irregularities in the submission process. The Town may also split proposals at its discretion. The Town further reserves the right to negotiate directly with any and all businesses concerning any matter related to any proposal. All Town request for proposals are prepared so as to afford all businesses the equal opportunity for fair and equitable competition. The Town assumes no liability or responsibility for any errors or oversights in the preparation and/or publication of proposals

4 LABOUR, MATERIALS AND INSURANCE SPECIFICATIONS PREFACE The following pages within this document outline the Town s request for proposals for fireworks contractors and specifications for the 2016 Canada Day Fireworks Display. Contractors are to be aware: The Town is soliciting proposals for fireworks contractors. The proposal format gives the Town greater flexibility in evaluating fireworks program proposals from Contractors; The Contractor will be given the opportunity to provide any variety of fireworks program packages as long as the proposal falls within the program budget; and All Contractor s proposals must be received by the Town of Midland no later than Friday, April 21, 2016 at 12:00 Noon. Instructions on mailing or delivering are detailed on the Invitation to Submit Proposals. CONTRACTOR SELECTION PROCESS Proposals received from fireworks Contractors will be evaluated on: the quality of the program proposal; the quantity of the program proposal; the Town s past experience with the Contractor, if any. The Contractor shall demonstrate within the proposals they are ready to provide the highest quality fireworks falling within the program budget and prepared to provide a qualified and experienced operator capable of handling and firing the program within industry guidelines and time frames set forth within these specifications. PROGRAM BUDGET The complete Canada Day Fireworks Program budget is a total of $10, (including applicable taxes). The Contractor s proposal shall include all elements and costs involved with the program including labour, materials and insurance as specified within this document. FIREWORKS QUALITY The contractor shall also note the following: All shells shall properly fit the mortars; All shells shall be the freshest possible with the least exposure to moisture or humidity. METHOD OF SET-UP AND FIRING OF AERIAL SHELLS The Town will require its 2016 Canada Day Fireworks Display to be fired by electronic means. A copy of the location setup and site plan layout is to be submitted to the Midland Fire Department for approval by Thursday June 16 th, 2016 latest

5 FIREWORK OPERATORS The Contractor has the option to select his/her own employees/operators/pyrotechnicians for the Town program. The Lead Pyrotechnician shall be a certified operator by an accredited organization adhering to the industry and governmental standards governing the handling and firing of fireworks. Fireworks crew members shall also be trained by the Contractor in the latest safety standards. The Lead Operator/Pyrotechnician shall be certified and all crew members trained formally by industry standards; and The Operator/Pyrotechnician will fire the aerial display by electronic means. People who handle and operate fireworks must complete certified training for the levels of: Display Assistant Display Supervisor Display Supervisor with Endorsements (if applicable) *The training is provided by the Explosive Regulatory Division (ERD) of Natural Resources Canada (NRCan).* SPECIFICATIONS FIREWORKS a) Aerial Shells The Contractor shall provide the Town with an all aerial display consisting of general aerial fireworks pieces. No ground displays. b) Contractor Proposal Options The Contractor has the option to submit any one, or more, program options not to exceed total cost of $10,000.00, including labor and insurance costs: Program and materials not to exceed $10, that may include: an Opening Barrage; the Core Aerial Display; a Finale At minimum the Contractor s proposal must contain the core aerial display and a finale. All program proposals must not exceed the $10, budget encompassing all expenses. c) Shell Selection The Contractor may provide an assortment of authorized domestic shells and import shells in 3, 4 and 5 calibre. The use of cakes to enhance the aerial display will be considered however it may not exceed 5% of the total program. The program shall consist of less expensive single-break shells, medium quality multiple-break shells/multicolor shells/multicolour report/flash report/salute shells and highest quality special/fancy shells

6 d) Shell Information and Listing In order for the Town to evaluate the aerial fireworks proposal by the Contractor, the Contractor shall provide the following information on the Proposal Form: 1. Type/Name of Shell 2. Colour 3. Shell Rating (Single Break, Multiple Break or Special/Fancy) 4. Number of Shells 5. Firing It is important for the Contractor to provide adequate information on Type/Name of Shell, Shell Rating and Number of Shells so the Town is able to evaluate the proposed program. The Contractor is asked to provide the highest quality shells within the framework of the program's budget. e) Shell Quality Distribution (1) Aerial Shells The Contractor shall be requested to identify the quality ranking of each aerial shell, i.e.: Single Break, Multiple Break, Special/Fancy, etc., on the worksheet forms. (2) Finale The finale shall consist of star shells and aerial salutes and any additional combination of aerial shells wicked and racked accordingly. The Finale should consist of a storied effect with low, medium height and maximum height breaks. f) Pre-Display Set-Up The 2016 Canada Day Fireworks Display shall be completely set-up prior to the start of the program. FIREWORKS BUDGET Total Budget Allocation is $10, inclusive. SUPPLIES, EQUIPMENT and TRAINING The Contractor shall provide all necessary supplies and equipment to successfully and safely operate and fire the Town display including, but not limited to: Mortars and racking to accommodate electronic firing [Mortar counts and sizes must match the number of shells in each category); Tarps and/or approved covering for all pre-set pieces; Shovels and other tools; Employee safety equipment including hard hats, ear and eye protection, first aid supplies, fire extinguishers and other safety equipment deemed necessary; Approved vehicles to transport fireworks and equipment; Other equipment deemed necessary; and Proper Training/Certification of all fireworks operators. DATE OF DISPLAY AND RAIN DATE The Canada Day Fireworks Display shall be conducted on Friday, July 1, 2016, beginning no earlier than 10:00 p.m. or when sufficient darkness sets in

7 a) Rain Date If the program cannot be fired because of rain, drizzle or adverse wind conditions, the program will be cancelled and fired the next day, Saturday, July 2, 2016 under the same time conditions or an alternate date to be determined by the Town. b) Cancellation Fees The Contractor will not assess the Town extra fees or charges if the display is cancelled and rain date is utilized due to adverse weather conditions. FIREWORKS OPERATORS The Contractor shall provide a knowledgeable, experienced and trained Lead Pyrotechnician to supervise the program set-up, firing, dismantling and post-display policing of the grounds. The Lead Pyrotechnician shall be trained and certified and familiar with all industrial, governmental codes regulating the safe handling and firing of fireworks. Auxiliary staff shall also be trained by the Contractor prior to the display. The Contractor shall provide to the Town the following employee information no later than Friday, June 3 rd, 2016; A complete listing of each employee hired by the Contractor for the event; Experience and/or training received by each employee; Written verification that each of the Contractor s employees are covered under Workmen s Compensation Insurance, as per Ontario statutory requirements; and the above is to be submitted on Contractor s letterhead. PROGRAM DISPLAY TIME CONDITIONS The Contractor shall fire the specified fireworks program in no less than twenty (20) minutes and no more than thirty (30) minutes. DELIVERY, INSPECTION, STORAGE, SET-UP, DISMANTLING AND UNEXPLODED SHELLS Delivery of fireworks shall be made in vehicles in conformance with all local, provincial, and federal laws. Delivery shall be made by contractor on the display date and coordinated with the Culture, Tourism and Special Events Manager, unless other approved arrangements are agreed to by contractor and Town. Upon delivery, the Town retains the right to inspect fireworks shells to make certain that the material is in conformance with specifications. A detailed packing list must accompany order. The Contractor may begin the set-up of mortars, finale racks, electronic rigging, etc., beginning at 9:00 a.m. on the display date and/or rain date or at a mutually agreed time/date. The Contractor must remove all mortars, finale racks, boxes, paper and trash at the conclusion of the display. All mortar holes are to be filled and replaced as found; and The Contractor shall be responsible for locating and disposing of all unexploded shells. The Contractor's employees shall search all areas around the firing site, including shallow water near the firing site for live shells. Two searches shall be conducted once immediately after the display and the second at day-break the following day. The Contractor is liable for damages associated with live shells left at the firing site

8 FIRING SITE AND SPECTATOR CONTROL a) Firing Site The 2016 Canada Day Fireworks Display shall take place at Little Lake Park in Midland. The Contractor shall fire the display on the volleyball courts in Little Lake Park. The Contractor shall select the exact locations, given wind conditions, etc., with approval from the Town's representative. b) Spectator Control by Police After 8:30 p.m. on the display date, the volleyball courts at Little Lake Park will be closed off to general and/or pedestrian traffic by the security/police coordinated by the Town. c) Spectator Control by Contractor The nearest body of spectators to the firing site is approximately 1,200' away separated by land. The security/police will do its best to stop and turn back pedestrians. The Contractor, however, must be especially vigilant of persons who may wander into the firing area. INSURANCE a) Worker's Compensation Insurance The Contractor shall purchase coverage and provide the following documents for confirmation; Clearance Certificate from WSIB Liability coverage of $2,000,000 (minimum) b) Comprehensive General Liability Insurance The Contractor shall purchase and provide a Certificate of Insurance, naming the Corporation of the Town of Midland as "additional insured" on all policies and related documents for the following Comprehensive General Liability Insurance: a) Bodily Injury - Combined Single Limits $2,000,000 (minimum) b) Property Damage - Combined Single Limits $2,000,000 (minimum) c) Auto Liability - Combined Single Limits $2,000,000 (minimum) c) Delivery of Certificates The Contractor shall provide Certificates of Insurance to the Town no later than June 3 rd,2016. The Certificates shall also indicate both the primary display date and the Rain Date policies are in effect. The Town of Midland is to be named "Additional Insured" upon all certificates. d) Proposal Form Complete submission must include Worksheet A, B and C as well as the Proposal Form reflecting costs involved with both Worker's Compensation and General Liability Insurance

9 HEALTH AND SAFETY HS-14 Contractor Contract and Pre-Job Checklist must be completed and signed along with all applicable documents enclosed as stated on the checklist and shall be submitted with the tender. TOWN CONTACT Nicole Major, Culture, Tourism and Special Events Manager 575 Dominion Ave, Midland, ON L4R 1R2 Tel: (705) ext EVALUATION OF PROPOSALS The Town will evaluate proposals based upon the quality of the program proposal, quantity of fireworks, quality of the fireworks, accuracy of the worksheets describing shell types, price of fireworks materials and ability to comply with insurance specifications. The Contractor's proposal will also be evaluated by specifically identifying the fireworks operator, loaders/tube cleaners, their experience and credentials

10 WORKSHEET A OPENING BARRAGE Provide information on all aerial shells you intend to furnish In the above noted component of the program. Type/Name of Shell Colour *Shell Rating # of Shells Firing REFERENCE Type: Shell Ratings: Single Break Two Break/Multiple Special Fancy Firing: Electronic

11 WORKSHEET B CORE AERIAL DISPLAY Provide information on all aerial shells you intend to furnish In the above noted component of the program. Type/Name of Shell Colour *Shell Rating # of Shells Firing REFERENCE Type: Shell Ratings: Single Break Two Break/Multiple Special Fancy Firing: Electronic

12 WORKSHEET C FINALE Provide information on all aerial shells you intend to furnish In the above noted component of the program. Type/Name of Shell Colour *Shell Rating # of Shells Firing REFERENCE Type: Shell Ratings: Single Break Two Break/Multiple Special Fancy Firing: Electronic

13 Date: PROPOSAL FORM PROPOSAL: Labour, Equipment, Materials and Insurance for the 2016 Canada Day Fireworks Display in Midland We the undersigned, do hereby agree to furnish all labour, equipment, materials and insurance for the Canada Day Fireworks Display in Little Lake Park, Midland in conformance with attached specifications for the following amount: Fireworks Opening Barrage - Worksheet A Core Aerial - Worksheet B Finale - Worksheet C Subtotal Fireworks $ $ $ $ Additional Expenses Labour/Related Expenses Required Insurance Coverage (as outlined) Other: (specify) Applicable Tax (HST) $ $ $ $ TOTAL PROPOSAL AMOUNT (Including fireworks, labour, insurance and other) $ Submitted by: FIRM: ADDRESS: PROVINCE: POSTAL CODE: BY: TITLE: SIGNATURE: Complete submissions must include applicable Worksheets (A, B and C) and the Proposal Form

14 Town of Midland Contractor Contract Health and Safety Agreement Period: to (year) In consideration of the Town of Midland permitting the Contractor to perform various services for and on behalf of the Town as and when required during the period specified above and other consideration the sufficiency of which is hereby acknowledged, it is agreed that: 1. The terms set out herein shall: a. be effective and applicable in relation to all contracts entered into between the Contractor and the Town and of Midland; b. prevail over any standard pre-printed clauses contained in the Contractors purchase orders (or similar) save and except where such clauses exceed the provisions set out herein; during the period specified above. 2. The Contractor shall at all times during the performance of the work comply with all applicable Federal, Provincial, or Municipal Occupational Health and Safety legislative requirements, applicable regulations, and all applicable industry standards and guidelines pertaining to the work being performed. 3. Where the Contractor employs supervisors and employees, the Contractor shall ensure that appropriate policies and procedures relating to health and safety aspects of the work, appropriate training and appropriate monitoring and enforcement of safety aspects of the work are carried out respecting supervisors and employees. 4. If a Contractor requires to Sub-contract work they were hired to perform for the Town of Midland, the Contractor hired by the Town of Midland must notify the Town of Midland immediately prior to hiring the Sub-contractor. Sub-contractors must be approved by the Town of Midland prior to being hired to perform the work by meeting the Town of Midland Health and Safety requirements, including but not limited to HS-14 Contractor Checklist and Contract. 5. If it is determined by the Town of Midland and agreed upon by the Contractor that the Contractor hired to perform the work shall become the Constructor, this contract is null in void and the Contractor must agree, comply with and sign the HS-14 Constructor Contract provided by the Town of Midland. Constructor as defined in the Occupational Health and Safety Act is; a person who undertakes a project for an owner and includes an owner who undertakes all or part of a project by himself or by more than one employer. 6. The Contractor shall be solely responsible for the means, methods, techniques, sequences, procedures or coordinating the work performed under the work being hired to perform unless specifically directed by the Town. The Contractor shall be solely HEALTH AND SAFETY FORM HS-14 March 2016 Page 1 of 3

15 Town of Midland Contractor Contract Health and Safety Agreement Period: to (year) responsible for ensuring that all supervisors and employees are informed of all known or foreseeable health and safety hazards at the work location. 7. The Town of Midland shall have access to the work site for the purpose of inspecting the work site to determine compliance with the Occupational Health and Safety Act and Regulations. It is understood if any violations of the Act are noted; the Town of Midland shall create an Order to Comply and will be submitted to the Contractor. All Orders must be dealt with in a timely manner. Failure to comply will result in a Stop Work until such orders are completed. 8. The Contractor shall furnish evidence of compliance with all requirements of the Workplace Safety and Insurance Act and the Workplace Safety and Insurance Board. Such evidence to include a certificate of good standing issued prior to the commencement of work and shall remain valid until completion of work. 9. The Town of Midland has the right to stop work if the Contractor does not supply proof of a valid WSIB Clearance Certificate while working for the Town and work will not commence until such documentation has been provided. 10. The Contractor shall furnish evidence of Liability Insurance (minimum $2,000,000, two million dollars), unless otherwise specified, prior to commencement of work and to establish coverage until completion of work prior to payment of any amounts due. 11. The Town of Midland has the right to stop work if the Contractor does not supply proof of a valid insurance certificate while working for the Town of Midland and work will not commence until such documentation has been provided. 12. The Contractor must provide a copy of its Health and Safety Policy to the Town of Midland upon request. The Contractor agrees that the Town of Midland s receipt of a copy of the Contractor s policy shall in no way be construed as the Town endorsing the contents of the same. 13. The Town s Corporate Health and Safety Policy and Procedure, respective Department s Standard Operating Procedures, WHMIS and other related documentation required by the Occupational Health and Safety Act are available to the Contractor. 14. The Contractor shall complete and supply to the Town of Midland the Contract Pre-Job Checklist HS-14 prior to commencement of work. 15. The Contractor agrees to indemnify and hold the Town of Midland harmless from and against any and all liability, loss or damage due to bodily injury or death to any third party or damage to property to the extent such bodily injury or death or damage to property is caused by the Contractors negligent performance and/or willful misconduct under this HEALTH AND SAFETY FORM HS-14 March 2016 Page 2 of 3

16 Town of Midland Contractor Contract Health and Safety Agreement Period: to (year) Agreement. As used herein, a third party shall not include the Contractor or the Town of Midland or the Council members, officers, employees or agents of the Contractor or the Town of Midland. 16. The Contractor expressly agrees and authorizes that the Town of Midland to defer payment of up to 100% of the labour portion of any invoice supplied by the Contractor at the sole discretion of and without liability to the Town of Midland, until all required documentation and information as set out in the HS-14 Contract Pre-Job Checklist has been received by the Town of Midland. 17. Except as expressly provided in this agreement, no amendment or waiver of this agreement shall be binding unless executed in writing by the party to be bound. No waiver of any provision of this agreement shall constitute a waiver of any other provision, nor shall any waiver of any provision of this agreement constitute a continuing waiver unless otherwise expressly provided. 18. A facsimile or electronic copy of an executed version of this agreement shall constitute an original. 19. The Contractor acknowledges this Agreement has been read and understands this agreement, and acknowledges they had the opportunity to obtain independent legal advice with respect to the Agreement and in any event has read and fully understand the terms set out in this Agreement. Contractor Company Name Name of Contractor Signature of Contractor Date HEALTH AND SAFETY FORM HS-14 March 2016 Page 3 of 3

17 TOWN OF MIDLAND Contract Pre-Job Checklist Date Revised: March 2016 (To be completed for all jobs under the Industrial and Construction Regulations) 1. A Safety Plan (if required) shall be submitted for review to the contact person responsible for the contract before the start date. 2. The contractor shall review the Town of Midland H&S manual where applicable prior to the start date. 3. An Emergency Plan for the contract (if required) shall be submitted to the contact person responsible prior to the start date. Company Name: Contractors Name: Contractor name and Phone #: address: Number of Staff Employed (Full and Part time): Contractor H&S Representatives Name and Telephone Numbers: Worker Representative: Management Representative: To be completed by all Contractors Documents/Licenses (check applicable boxes) Provided Posted N/A WSIB Clearance Certificate Independent Operator Status (WSIB Questionnaire to be completed) Liability Insurance (minimum $2,000,000 unless otherwise specified ) Current WSIB Neer Statement Company s Health and Safety Policy Copies of MSDS for chemicals on site Electrical Licenses Copy of trade licenses for skilled trades Other Licenses (list all applicable Licenses): Health and Safety Form HS-14 April 2010 Page 1 of 4

18 TOWN OF MIDLAND Contract Pre-Job Checklist Date Revised: March 2016 (To be completed for all jobs under the Industrial and Construction Regulations) Current Training/Certificates applicable to the Job being performed (provide copies of applicable certificates) WHMIS Generic (Legislation overview) WHMIS Specific Chemical Review First Aid Fall Protection Working at Heights Transportation of Dangerous Goods Confined Space Traffic Control Emergency Procedures Trenching/Shoring/Excavation Lock out/tag out Forklift Chainsaw Electrical Safety- CSA Z462 Training (and any other applicable Electrical training) Ladder Crane/Rigging Safety Manual Material Handling Rescue/Retrieval Designated Substances Yes/ Provided No N/A MOL Worker Awareness in 4 steps or Supervisor awareness in 5 steps Other (please list and provide) Personal Protective Equipment Requirement (specific to the job) (Contractors must provide and ensure PPE is maintained in good order) Hard Hats Safety Glasses Safety Goggles Face Shields Hearing Protection Safety Boots Gloves Safety Harness (full body) Personal Flotation device/life jackets Traffic Vests Respiratory Protection Protective Clothing (gowns, masks, tyvek etc) Other (please specify) Yes No N/A Health and Safety Form HS-14 April 2010 Page 2 of 4

19 TOWN OF MIDLAND Contract Pre-Job Checklist Date Revised: March 2016 (To be completed for all jobs under the Industrial and Construction Regulations) Notices to be submitted to the Ministry of Labour applicable to this project: Yes N/A Trenching Excavation Notice of Project Work Permits Yes No N/A Lock out/tagout Other: Applicable to Construction Projects to be posted at the site Posted N/A Confined space training certification Confined Space entry permits Copy of OHSA posted Copy of WHMIS Regulations/Specific Chemical Review First Aid Training Certificates and First Aid kit Form Registration of Constructors and Employers Engaged in Construction Notice of Project Job Site Civic Address in a conspicuous location Inspection logs of equipment on site (MTO and OHSA) Designated Substance List (please list) Hazard Assessments Conducted with Project Yes No N/A Lockout/Tag Out items Pressurized Lines Hearing Protection Traffic Control Site Plan (signs, barricades, flagging etc) Trenches Confined Space Lift Devices Fall Protection Pedestrian Safety Compressed Air Overhead Wires Traffic Control Environmental Issues Other (please list) Health and Safety Form HS-14 April 2010 Page 3 of 4

20 TOWN OF MIDLAND Contract Pre-Job Checklist Date Revised: March 2016 (To be completed for all jobs under the Industrial and Construction Regulations) Corporate Electrical Program Please refer to the Electrical Work Acknowledgement Form to comply with our Electrical Program. It is understood that the Contractor will comply with the Town of Midland Electrical Requirements any time where electrical work will be performed. OTHER: Provided Posted Available N/A Please refer to the OHSA Construction Regulations and/or Industrial Regulations and the Town of Midland H&S manual and list any other safety issues, and provide any other applicable documents required not mentioned in this form. The undersigned hereby acknowledges and represents that the information set out in the form is accurate as of the date of signing. Any changes of the required information, training documentation, licenses and/or certificates going forward of the signed date will be forwarded to the Town of Midland immediately. This also includes all required information on any new hires from the date of signing. Non-compliance of Town Policies and Legislative requirements may result in suspension of work for the Town of Midland for up to 12 months. This shall be determined on a case by case basis by the Town Manager. The Contractor understands that the Town of Midland will defer payment of up to 100% of the labour portion of any invoice supplied by the Contractor at the sole discretion of and without liability to the Town of Midland until all required documentation is received by the Town of Midland. Dated at this day of (location) (month) (year) Signature of Authorized Contractor Name of Contractor Title Health and Safety Form HS-14 April 2010 Page 4 of 4