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STATUS:
REJECTED
273 D -PBS-UB Kinsey-Palmview ES FCA Renovations
General Information
Subcontractor:
FLORIDA BLACKTOP, Inc
Subcontractor Project Manager:
Robert Shaouy
Phone #:
954-275-9700
Email:
SECTION #1: Job-Site Specific Accident Prevention Plan
Please download the documents you wish to review.
Key personnel
Emergency List
OSHA 300
Appointment Letter
Basic Safety AHA:
7.-
Do you plan to perform work at heights greater than 6 feet at any time using ladders, scaffolds, or any aerial work platform (AWP)?
NO
8.-
Do you plan to perform any excavation work at any point during your project?
NO
9.-
10.-
Do you anticipate performing any electrical or demolition work at any stage of your project?
NO
Attach a copy of your Certificate of Insurance (COI):?
SECTION #3: Equipment Certification (If Applicable)
Do you plan to use any of the following equipment during your activities on the project?
Scissor Lift Use? | Boomlift? | Forklift? | Welder? | Heavy Equipment? |
|---|---|---|---|---|
NO | NO | NO | NO | YES |
If you answered “Yes” to any of the previous questions, please attach the certificate(s) of the operator(s) below.
Person Responsible for Submitting the Information:
Name:
Maria Olmeda
Position:
Operations Assistant
Email:
Signature:
⚠️ For LEGO CO Safety Department Use ONLY
Observations:
- Attach the appropriate Safety Plan. The document you submitted does not constitute a Safety Plan.
- Attach the OSHA 30 certificates of your supervisors.
- Attach the CPR/First Aid certificate of your field supervisor for this project.
3/17/2026 10:57 AM
Observations:
- Attach the appropriate Safety Plan. The document you submitted does not constitute a Safety Plan.
- Attach the OSHA 30 certificates of your supervisors.
- Attach the CPR/First Aid certificate of your field supervisor for this project.
03/19/2026 2:28 PM
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