Release Of Liability printable pdf download

Release Of Liability

Connecticut

7009

Release of Liability for On-site Visit

Division Of

By Other Than State Employee

Construction Services

Page 1 of 1

Release of Liability

In connection with a request from:

Visitor’s Name:

Print Visitor Name

Visitor’s Company:

Print Visitor’s Company Name

Visitor’s Company Address:

Print Visitor’s Company Address

To enter upon State of Connecticut property located at:

Project Address:

Print Project Address

The State of Connecticut has agreed that permission for such Site Visits may be granted at the

discretion of the Construction Administrator,

CA Name:

Print CA Name

The undersigned certifies that the undersigned will bring no action or otherwise make a claim against the

State of Connecticut or any subdivision thereof for any injury or damage to person(s) or property which may

be sustained or incurred while on the premises of the:

Name of State Facility:

Print Facility Name

The undersigned represents that the undersigned’s presence at the above State Facility is for the sole

purpose of observing the progress of construction and that the undersigned will take no action other than that

which is required to conduct said observation. The undersigned understands that neither the State of

Connecticut nor any employee or official thereof makes any representation about the safety of the premises

and agrees that any action taken in furtherance of said observation is at the undersigned’s sole risk. The

undersigned further agrees to take no action that would place him in a position of danger, to heed all warnings

or instructions by on-site officials, and to act with the utmost care and caution while conducting said

observation.

Visitor Name:

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Visitor Signature:

Visitor Written Signature

Date

END

CT DAS – 7009 (Rev: 07.20.15)

7000 – Construction Phase Forms

Release Of Liability