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' SECTION 00454 on Sworn Statement Under the Florida Trench Safety Act THIS FORM MUST BE SIGNED BY THE BIDDER WHO WILL BE RESPONSIBLE FOR THE EXCAVATION WORK (" BIDDER"), OR ITS AUTHORIZED REPRESENTATIVE, IN THE PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO ADMINISTER OATHS , 1 . This Sworn Statement is submitted with Project No. 0545 & 0370 for 66th Avenue Roadway Improvements (S . R. 60 to North of 49th Street) ONE 2. This Sworn Statement is submitted by Dickerson Florida , Inc . (Legal Name of Entity Submitting Swom Statement) 1 hereinafter " BIDDER" . The BIDDER'S address is _ 3122 N . 25th St . , Ft . Pierce , FL 34946 BIDDER's Federal Employer Identification Number (FEIN) is 56 - 1327509 3 . My name is Larry To Dale and my relationship to the BIDDER Pres1denit Name of Individual Signing) is (Position or Title) I certify, through my signature at the end of this Sworn Statement, that I am an authorized representative of the BIDDER . 4 . The Trench Safety Standards that will be in effect during the construction of this Project are contained within the Trench Safety Act, Section 553 . 60 et. seta . Florida Statutes and refer to the applicable Florida Statue(s) and/or OSHA Regulation(s) and include the "effective date" in the citation(s) . Reference to and compliance with the applicable Florida Statute(s) and OSHA Regulation(s) is the complete and sole responsibility of the BIDDER . Such reference will not be checked by OWNER or ENGINEER and they shall ' have no responsibility to review or check the BIDDER's compliance with the Trench Safety Standards, 5 . The BIDDER assures the OWNER that it will comply with the applicable Trench Safety Standards. i�r D,6 . The BIDDER has allocated and included in its bid the total amount of $ , based on the linear feet of trench to be excavated over five (5) feet deep, or compliance with the applicable Trench Safety Standards , and intends to comply with said tan p[ds by instituting the following specific method(s) of compliance on this Project:-. ! 75e2 adc 14 The determination of the appropriate method(s) of compliance is the complete and sole responsibility of the BIDDER. Such methods will not be checked by the OWNER or ENGINEER for accuracy, completeness, or any other purpose . The OWNER and O ENGINEER shall have no responsibility to review or check the BIDDER's compliance with the Trench Safety Standards. OD . 7 . The BIDDER has allocated and included in its bid the total amount of $ ' based on the square feet of shoring to be used for compliance with shoring safety requirements and intends to comply with said shoring requirem is by institute g the following specific method(s) of compliance on this Project: _ T n j _ m Q� 00454 - Florida Trench Safety Act - REV 04-07.doc 00454 - 1 F:"Ic WorkslENGINEERING DIVISION PROJECTSIM45mMM Ave SR60 to 57th St (AreaditpAdrrAWA3d 0=rrants 0454 - Florida Trach Safety Act . REV 040740o