Contractor Compliance Application

Contractor Compliance Form

Project Name(Required)

Location(Required)

Street Address City Province Postal Code

Pre-Start Meeting Location(Required)

Street Address City Province Postal Code

Meeting Date(Required)

Contractor Firm Name(Required)

Prime Contractor(Required)

Yes

Contractor Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone Number(Required)

Fax Number

Email(Required)

24 Hour Emergency Phone Number(Required)

WCB Registration Number(Required)

Notice of Project Completed (WCB Regulation 20.2)(Required)

Yes

Not Applicable

Contractor Representative Name(Required)

Phone Number(Required)

The Contractor:

Consent(Required)
I agree to the contractor acknowledgements below:
Acknowledges the appointment of contractor

Understands that in any conflict of directions, Workers Compensation Act and OH&S Regulations shall prevail

Has been informed of any known designated substances and other known pre-existing workplace hazards (Pre-Contract Hazard Assessment Form)

Will communicate hazards to anyone who may be affected and ensure that appropriate measures are taken to effectively control or eliminate the hazards

Will immediately report to the Village any known hazards that are found during the contract

Understands that written documentation (e.g. safety program, notes, records, inspections, meetings etc.) on all health and safety issues must be available upon request to the Village and/or to a WCB Officer at the workplace

Will ensure all equipment to be used on the project complies with OH&S Regulations and is maintained in a safe working order and all necessary personal protective equipment is made available and used by employees

Will ensure that all workers are suitably trained and competent to perform the duties for which they have been assigned

Will provide safety orientations for all new workers

Will assess and coordinate the first aid requirements

Will provide MSDS for all controlled products brought into the workplace

Assumes responsibility for the health and safety of their workers and for ensuring compliance by their workers with the Workers Compensation Act and OH&S Regulations

Understands any WCB violation by the Contractor may be considered a breach of contract resulting in possible termination or suspension of the contract and/or any other actions deemed appropriate at the discretion of the Village

Understands that the Village may inspect the project and direct the Contractor regarding design, timeliness or quality. The Village may also randomly inspect health and safety activities as part of its due diligence

Understands any penalties, sanctions or additional costs levied against the Contractor (prime) will be the responsibility of the Contractor (prime)

Ensure that all documentation provided to the Village is accurate and up to date (e.g. WCB Clearance Letter)

Contractors must deliver the following documentation when returning this document:

Completed Contractor Compliance Form(Required)
Max. file size: 512 MB.

WCB Clearance Letter(Required)
Max. file size: 512 MB.

VOA Business License(Required)
Max. file size: 512 MB.

Completed Hazard Assessment Form(Required)
Max. file size: 512 MB.

Certificate of Insurance(Required)
Max. file size: 512 MB.

By signing this I agree as a representative of the contracted firm noted in this document to assume responsibilities of the Contractor for this project

Contractor Representative (Prime) signature(Required)

Date(Required)
MM slash DD slash YYYY

Please note to have a completed demolition package and application, you will also have to submit the Pre-Contract Hazard Application as part of the demolition package application. We also suggest you review page 4-23 of our Demolition-Package to ensure you aren’t missing any steps. Review Appendix A on page 4 to go over the contractor health & safety checklist and program guide. Review page 5 for details on how to submit a Notice of Project form – WorkSafeBC. We also recommend reviewing pages 16-20 of the Demolition-Package for Fire Safety Planning for construction and demolition sites, and pages 21-23 for our Decommissioning Septic Tanks Information guide.

Personal information requested on this form is collected under the authority of Section 26 of the Freedom of Information and Protection of Privacy Act, as amended. The information gathered will be used to deliver or evaluate the program or activity of the Village of Anmore that is associated with this form. Questions about the collection, use, and disclosure of this information should be directed to village.hall@anmore.com

Contractor Compliance Form

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