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1 <br />5 <br />1 <br />A <br />I <br />LI <br />Safety <br />Competent or Qualified Person Designation Form <br />Jobsite City & State: <br />Store / Club #: <br />Construction Start Date: <br />Expected Construction Complete Date: <br />The person(s) below have been designated by the General Contractor as a "Competent Person" per OSHA guidelines and are now dele- <br />gated the responsibility and authority for coordinating activities and operations covered by the designation(s) for which they have <br />been deemed competent. <br />*A Competent Person must be listed IF the discipline or work activity occurs on the jobsite. <br />Work Activity / Discipline <br />The list of work activities that require a Competent <br />or Qualified person includes but is not limited to: <br />Signature of Competent or Qualified <br />Person (whichever is required) <br />Company Name <br />Electrical <br />Fall Protection <br />Scaffolds / Ladders <br />Cranes <br />Trenching / Excavation <br />Concrete & Masonry <br />Welding & Cutting <br />Steel Erection <br />Toxic & Hazardous Substances <br />Demolition <br />Health & Environmental Controls <br />PPE & Life Saving Equipment <br />Blasting & Explosives <br />Underground Construction <br />_T <br />Note: This Form is required by Contract Compliance Spec Section 3.6.1.5 and must be posted on the Wall of Information in the General <br />Contractors jobsite office. <br />1 0706 - Zephyrhills, Florida - 16592140 February 16, 2017 <br />01351-39 <br />