Fillable COVID-19 Essential Critical Infrastructure Workers Form (Town of Los Gatos)

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COVID-19 Essential Critical Infrastructure Workers Form (Town of Los Gatos)

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Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031
408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca
TOWN OF LOS GATOS
COVID-19 ESSENTIAL CRITICAL INFRASTRUCTURE WORKERS FORM
SITE
ADDRESS
PERMIT #
DATE
Owner ................................................................................................................................................
Address .............................................................................................................................................
Project Type:
Single Family
Multi Family
Commercial
Mixed-Use
Right-of-Way
1
Email…................................................ .......................Phone……………… ...............................
Contractor.......................................................................... Title .........................................................
Address .............................................................................................................................................
Email ................................................................................. Phone .....................................................
SELECT TYPE OF PROJECT:
SMALL CONSTRUCTION PROJECT (SCP)
For Residential projects: any single-family, multi-family, senior, student, or other residential construction, renovation, or
remodel project consisting of 10 units or less. This SCP Protocol does not apply to construction projects where a person is
performing construction on their current residence either alone or solely with members of their own household.
For Commercial projects: any construction, renovation, or tenant improvement project consisting of 20,000 square feet of
floor area or less.
For Mixed-Use projects: any project that meets both Residential and Commercial specifications above.
LARGE CONSTRUCTION PROJECT (LCP)
For Residential projects: any single-family, multi-family, senior, student, or other residential construction, renovation, or
remodel project consisting of more than 10 units.
For commercial projects: any construction, renovation, or tenant improvement project consisting of more than 20,000 square
feet of floor area.
For construction of Essential Infrastructure: any project that requires five or more workers at the jobsite at any one time.
Safety Compliance Officer (SCO) ........................................................................................................................................
Company .................................................................................. Address .............................................................................
Email ......................................................................................... Phone ................................................................................
Jobsite Safety Accountability Supervisor (JSAS) [for LCP only] .........................................................................................
Company .................................................................................. Address .............................................................................
Email ............................................................... Phone ............................................... OSHA-30 Cert #: ..............................
I read and will comply with all COVID-19 protocols issued by the County of Santa Clara and agree a building inspection may be
cancelled due to the jobsite being out of compliance with all COVID-19 protocols. [Appendix B-1 for SCP or Appendix B-2 for LCP].
I understand the SCO is required to compile a daily written verification that the jobsite is compliant with the components of the SCP or
LCP protocols. All written verification forms shall be available upon request prior to all scheduled building inspections. For LCP jobsites,
written assessment forms from the JSAS shall be sent to the Building Official within seven calendar days of each jobsite visit.
I understand the SCO shall maintain a Daily Attendance Log of all workers and visitors including name, address, phone number and
email address. The attendance log shall be available upon request prior to all scheduled building inspections.
Owner Signature: ________________________________________ Print:________________________________________ Date:__________________
Contractor: _____________________________________________ Print:________________________________________ Date:__________________
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Town of Los Gatos • Community Development • Building Division • 110 E. Main St., Los Gatos, CA 95031
408.354.6876 • www.losgatosca.gov • www.facebook.com/losgatosca
DAILY ATTENDANCE LOG
Project Address: __________________________________________ Building Permit #: ______________________
Safety Compliance Officer: __________________________ Phone: __________________ Date: _______________
Company: ____________________________________ Address: _________________________________________
Worker/Visitor Name
Address
Phone
Email
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COVID-19 Essential Critical Infrastructure Workers Form (Town of Los Gatos)

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Completed 3 August 2020

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