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(Nazwa i adres Wykonawcy) WYKAZ OSB, KTRE BD UCZESTNICZY W WYKONYWANIU ZAMWIENIA  potwierdzenie speBnienia warunku podmiotowego SkBadany do zadania ,,Przebudowa drogi gminnej nr 350046T Chebdzie-Lubachowy na odcinku o dBugo[ci 1000 m Lp.Nazwisko i imiZakres wykonywanych czynno[ci Kwalifikacje zawodowe tj. rodzaj i numer uprawnieD budowlanychOsoby bdce w dyspozycji wykonawcy/ oddane do dyspozycji przez inny podmiot1Kierownik budowyUprawnienia budowlane do kierowania robotami budowlanymi wspecjalno[ci drogowej, posiadajcym do[wiadczenie w peBnieniu funkcji kierownika budowy lub robt w tym co najmniej 1 przedsiwzicia zwizanego z budow lub przebudow lub remontem drogi/drg. Nr uprawnieD & & & & & & & & .. Do[wiadczenie jako kierownik robt/ budowy zostaBo nabyte na nastpujcych inwestycjach: Nazwa inwestycji:& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. Data zakoDczenia inwestycji:& & & & & & & & & & & & & & & & & & & & & & & & & & ..  Vpr~ & ( 4 > 6 8 @ B ˸q`qOq>>0qhk,CJOJQJ^JaJ h-hCJOJQJ^JaJ h-h\CJOJQJ^JaJ h-h]e2CJOJQJ^JaJ h-h+CJOJQJ^JaJ h-hPCJOJQJ^JaJ#h2chP5CJOJQJ^JaJ$h2ch CJOJQJ^J_HaJ$h2chk,CJOJQJ^J_HaJ$h2chMiVCJOJQJ^J_HaJ h2ch4CJOJQJ^JaJ h2chq CJOJQJ^JaJ@ v x R | * 2 R  zzzzzz/$$& #$/Ifa$b$gd$$x$& #$/G$Ifa$b$gd$$-DM a$gd r$a$gd w /$da$gd]e2m$']'gdP']'gd+ $xa$gd+%$xx^`a$gdB F t v x 6 P R x z | ïp]E/*h-hY5CJOJQJ\^JaJtH.h-h]e25CJOJQJ\^JaJsHtH$h-h]e2CJOJQJ^J_HaJ(h-h"O5B*CJOJQJaJph(h-hIV5B*CJOJQJaJph(h-h]e25B*CJOJQJaJph'h-hP6CJOJPJQJ^JaJ'h-h'6CJOJPJQJ^JaJ'h-h+6CJOJPJQJ^JaJ'h-h6CJOJPJQJ^JaJ | ( * 2 P R  dxDZǞxeeN;e%h-hTB*CJOJQJaJph,h-hTB*CJOJQJ]_HaJph%h-h%B*CJOJQJaJph(h-h{5B*CJOJQJaJph h-h{CJOJQJ^JaJ%h-h{B*CJOJQJaJph+h-h{5B*CJOJQJ\aJph'h-h{5@CJOJQJ^JaJ#h-h r5CJOJQJ^JaJ#h2ch2c5CJOJQJ_HaJ 2$x$& #$/G$Ifa$b$gd$kd$$Ifr6 Eg-6;N"j   6 264ae4p2yt$ vd v/ & F-d$IfgdT/d$& #$/If^b$gd$/ & F-d$& #$/Ifb$gd{/$$If]a$gd% /$Ifgd%/$$& #$/Ifa$b$gd$/$& #$/Ifb$gd$ Vv 0 6 d &!!!!">"տէwaaaaaL(h-h{5B*CJOJQJaJph+h-hT5B*CJOJQJ\aJph.h-hT5>*B*CJOJQJ\aJphU+h-h{5B*CJOJQJ\aJph.h-h{5>*B*CJOJQJ\aJph+h-hT5B*CJOJQJ\aJph+h-h%5B*CJOJQJ\aJph(h-h%5B*CJOJQJaJphZamawiajcy: & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & Nazwa inwestycji:& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .. Data zakoDczenia inwestycji:& & & & & & & & & & & & & & & & & & & & & & & & & & .. Zamawiajcy: & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & WBasne / oddane do dyspozycji*Uwaga! o[wiadczam(my), |e osoba wskazana, bdzie uczestniczy w wykonywaniu zamwienia i posiada uprawnienia wymagane w postawionym warunku w SWZ i mo|e sprawowa wymienion funkcj zgodnie zPrawem Budowlanym. * niepotrzebne skre[li ( je|eli wykonawca pozostaje w stosunku umowy cywilno prawnej pozostawiamy wBasne)       INCLUDEPICTURE "https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQjRQModZFoFVA3v1LmdX9QigzBrhn4iaJ9iw&usqp=CAU" \* MERGEFORMATINET    "Europejski Fundusz Rolny na rzecz Rozwoju Obszarw Wiejskich: Europa inwestujca w obszary wiejskie" Numer referencyjny: GKZ.271.1.7.2023 PAGE  (podpis) Dokument musi by podpisany kwalifikowanym podpisem elektronicznym lub podpisem zaufanym lub elektronicznym podpisem osobistym &!!!!">"/$$& #$/If^a$b$gd$/d$& #$/If^b$gd$/d$If^gdT>"@"N"n""###$$$$$$$$$$$$$$$$$$̨̻zvvzvvzvvzvvcTh2ch2cCJOJQJaJ%jh2ch2cCJOJQJUaJhl1*jhl1*U%h-hJ(!B*CJOJQJaJph%h-hLSB*CJOJQJaJph%h-h]e2B*CJOJQJaJph h-hCJOJQJ^JaJ h-h]e2CJOJQJ^JaJ&h-h]e25CJOJQJ\^JaJh-h{CJOJQJaJ>"@"#$$$S@;20/ $gd"/gd]e2c$xx[$\$]a$gdckd&$$Ifr6 Eg-6;N"j  6 64ae4p2yt$$$$$$$$$&''''(((()))$a$gd^$a$gd $(^(a$gdCp$L,dh^L,`a$gdALh]hgd2T &`#$gd8gd2cgd'$a$gd2c$$$ &&&&&,&.&F&H&&&'''''ݷݤݘq`L<h>C=h'5CJOJQJaJ'h>C=h'5CJOJQJaJmHsH!h2c5CJOJQJaJmHsH"h2ch'5CJOJQJ\aJ(h2ch2c56CJOJQJ\]aJh2cCJOJQJaJ%jh2ch2cCJOJQJUaJ%j h2ch2cCJOJQJUaJ%jh2ch2cCJOJQJUaJh2ch2cCJOJQJaJ%jh2ch2cCJOJQJUaJ'''''''(((((())))) )һra]J%h-hJ(!B*CJOJQJaJphhl1* h!5;CJOJQJRHZaJ#hhAL6CJOJQJ^JaJhsA6CJOJQJ^JaJ h!0Jjh!0JUh!'hTbh'5CJOJQJ^JmHsH-h%5CJOJQJ_HaJmHnHsHtH-hPaZ5CJOJQJ_HaJmHnHsHtH+h>C=h'5CJOJQJ_HaJnHtH)) )/ $gd"51h0:pi@A .!"#8$% $$$If!vh#v;#v#vN#v"#vj :V   6 26,,5;55N5"5j / 4 e4p2yt$$$If!vh#v;#v#vN#v"#vj :V  6 6,5;55N5"5j / 4 e4p2yt$Dd -dZ6  3 A?RwJ>HQ(qkHAFcwJ>HQ(q AExifMM*  ;((1$2؇i$ q' q'Adobe Photoshop CC 2014 (Macintosh)2015:07:06 09:17:530221Xrz( HH Adobe_CMAdobed            k" ? 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