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SECTION 00454 - Sworn Statement Under the Florida Trench Safety Act <br /> THIS FORM MUST BE SIGNED BY THE BIDDER WHO WILL BE RESPONSIBLE <br /> FOR THE EXCAVATION WORK ( " BIDDER") , OR ITS AUTHORIZED <br /> REPRESENTATIVE, IN THE PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO <br /> ADMINISTER OATHS , <br /> 1 . This Sworn Statement is submitted with Project No . 9810- 13 for 66th Avenue Roadway <br /> Improvements — Phase 2 (4th Street to 16th Street) <br /> 2 . This Sworn Statement is submitted by _ C7oeAgw4 - <br /> �ro�-!,e✓s Coicsfit[�i�✓J �.G.L <br /> (Legal Name of Entity Submitting Sworn Statement) <br /> hereinafter " BIDDER" . The BIDDER's address is _ <br /> YVVl UJWkeVLtL V 12tu r y RrA 4;w l- paer c e f=L 349 L4 7 <br /> BIDDER's Federal Employer Identification Number ( FEIN ) is z o3 cQo g zq <br /> 3 . My name is e ,n Czve.: VeA*� and my relationship to the BIDDER <br /> (Print Name of Individual Signing) <br /> Is <br /> (Position or Title) <br /> I certify, through my signature at the end of this Sworn Statement, that I am an <br /> authorized representative of the BIDDER. <br /> 4 . The Trench Safety Standards that will be in effect during the construction of this Project <br /> are contained within the Trench Safety Act Section 553 . 60 et seq Florida Statutes and <br /> refer to the applicable Florida Statue (s ) and/or OSHA Regulation (s) and include the <br /> "effective date" in the citation (s) . Reference to and compliance with the applicable <br /> Florida Statute (s ) and OSHA Regulation (s) is the complete and sole responsibility of the <br /> BIDDER. Such reference will not be checked by OWNER or ENGINEER and they shall <br /> have no responsibility to review or check the BIDDER's compliance with the Trench <br /> Safety Standards . <br /> 5 . The BIDDER assures the OWNER that it will comply with the applicable Trench Safety <br /> Standards . <br /> 6 . The BIDDER has allocated and included in its bid the total amount of $ /o pdp 00 <br /> based on the linear feet of trench to be excavated over five (5 ) feet deep , or compliance <br /> with the applicable Trench Safety Standards , and intends to comply with said standards <br /> by instituting the following specific method (s ) of compliance on this Project: ter , <br /> `c w� T%Gr1 cG� q�jox S G a ewi 2 <br /> i <br /> The determination of the appropriate method (s ) of compliance is the complete and sole <br /> responsibility of the BIDDER . Such methods will not be checked by the OWNER or <br /> ENGINEER for accuracy, completeness , or any other purpose . The OWNER and <br /> ENGINEER shall have no responsibility to review or check the BIDDER's compliance <br /> with the Trench Safety Standards , <br /> 7 . The BIDDER has allocated and included in its bid the total amount of $/V oot <br /> j based on the square feet of shoring to be used for compliance with shoring safety <br /> requirements and intends to comply with said shoring requirements by instituting the <br /> following specific method (s ) of compliance on this Project : �k� ,. , ,� u tl <br /> 5 LO PS.tJI►1 <br /> I <br /> j <br /> 00454 00454 - Florida Trench Safety Act - REV 04-07.doc <br /> - 1 <br />