AGREEMENT between BROWARD COUNTY and Cummings ...

Form-5
Notice of Work Completion Form 5
Numbers reference attached instructions
A. General Information
1
Contractor:
2
Under Contract with:
Contract #:
3
(Project Name)
4
Description of Work Performed:
5
Date Work Completed:
6
Date this Contract Completed:
Exhibit 2
Page 138 of 379
BROWARD COUNTY, FL
Page 1 of 2
B. Work Completion
The following Subcontractors have completed their Work at the Project Site(s):
(Add attachment if more space is needed)
1
a b c d
Subcontractor’s Name Contract Number Description of Work Date Completed
Location of your payroll records (Receipt of this form will initiate the payroll audit process):
Address:
2
City, State, Zip Code:
Contact/Phone #:
C. Signature Block
The undersigned acknowledges request for termination of Coverage under the OCIP as of the date indicated above for the specified Contract. Should we return to the
work Site(s), we will be working under our own insurance program and must provide BROWARD COUNTY with a Certificate of Insurance showing our own Coverage
as detailed in our contract.
SIGNED BY:
1
Name & Title
Date
APPROVED BY:
2
Construction Manager (Name & Title)
Date
Fax or Mail to: Diana Schrader Phone: 407.804.2418
Aon Risk Services, Inc. of Florida Fax: 407.804.1077
400 International Parkway, Suite 100 Email: Diana. Schrader@aon.com
Heathrow, FL 32746