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i SECTION 00454 - 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 . 9 . This Sworn Statement is submitted with Proect No. 0208 for Bridge Replacement and Roadway Improvements on 82"d Avenue at 4 Street. i 2 . This Sworn Statement is submitted by Lucas Marine Acquisition Company, LLC (Legal Name of Entity Submitting Sworn Statement) hereinafter " BIDDER" . The BIDDER's address is _ 3130 SE Slater St. , Stuart, FL 34997 BIDDER's Federal Employer Identification Number ( FEIN ) is 45-2733702 3 . My name is wade Diekman and my relationship to the BIDDER (Print Name of Individual Signing IS Vice-President (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 . seg . 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 i Standards . 6 . The BIDDER has allocated and included in its bid the total amount of $ 2 , 500 . 00 based on the linear feet of trench to be excavated over five (5) feet deep , for compliance with the applicable Trench Safety Standards , and intends to comply with said standards by instituting the following specific method (s ) of compliance on this Project: Sloping i 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 ENGINEER shall have no responsibility to review or check the BIDDER's compliance with the Trench Safety Standards . 7 . The BIDDER has allocated and included in its bid the total amount of $ N/A based on the square feet of shoring to be used for compliance with shoring safety requirements and intends to comply with said shoring requirements by instituting the following specific method (s ) of compliance on this Project: 00454 - Florida Trench Safety Act - REV 04-07 .doc 00454 - 1 I r .. icon I% S^ ,." ,.oink+ non �+ nil, c++ n A,.,:rah;A A,,,Janne Sd _ M^n A= Tro h .q,f,h Ar - RFV rwd