DECLARATION OF COMPETENT SUPERVISION - M.J. Dixon

[Pages:1]DECLARATION OF COMPETENT SUPERVISION

In the matter of contract work performed by (_________________________________)

Name of Company

at the (_________________________________________).

Name of Project

1.

I am the (_____________________) of (________________________________) and as such

Title

Name of Company

have knowledge of the matters herein stated.

2.

(____________________________) is a (_________________________) with its head office

Name of Company

choose 1: Proprietorship/Partnership/Corporation

located at (________________________________________) and has carried on business as a

Address

Contractor since on or about (_________________)

Date

3.

(____________________________) has since (___________________) had in place a health

Name of Company

Date

and safety policy and has developed and maintains on an annual basis a program to implement

the written Occupational Health and Safety Policy. A copy of this policy and program is available

for inspection upon request.

4.

(___________________________) will employ for this project a supervisor or supervisors

Name of Company

who are competent persons, and specifically the following person(s) who:

a. are qualified because of knowledge, training and experience to organize the project work and

its performance;

b. are familiar with the Act and Regulations for Construction Projects that apply to the Project

work; and

c. have knowledge of any potential or actual danger to health and safety at the Project.

5.

(___________________________) will employ for the purpose of this Project the following

Name of Company

competent supervisors:

1. ________________________________________________

2. ________________________________________________

3. ________________________________________________

No supervisor other than those named above or attached hereto by addendum shall work on the Project in a supervisory capacity.

6.

The Supervisor(s) employed by (__________________________________) has/have

Name of Company

completed the necessary health and safety courses to be considered a competent person to

undertake work described in the Contract. Proof of such training is attached hereto for the

persons named above and will be included by addendum for any future supervisors assigned to

the Project.

____________________________________ Company Official

_________________________ Date

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