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IL IL It a 9, a a <br /> STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 700-010-36 <br /> CERTIFICATION OF SUBLET WORK CONSTRUCTION . <br /> 10/07 <br /> TO : THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br /> f lG L � C' , , ( Sea ! ) <br /> General Info <br /> Request No . : Prime Contractor Contractor ' <br /> FAP No. . <br /> Fin . Proj . ID : Byr ''`e <br /> Cont. No . : <br /> F . E . I . D . # IF CORPORATION , AFFIX SEAL <br /> � � �l <br /> Count )iiZvv eXv C Lf L — 13 tc� C" cf`� k�v G <br /> Total Contract Amount fi Address <br /> Total Work <br /> 2.'_ Total Amt a: <br /> Subcontractor Name ; FEID # Subcontract to Whom Work Description Sublet <br /> V. 2 <br /> C� o h Vic. ( t I ►u t� b CsuC I i1L <br /> t t�Ube ► I �► �12522� N , l lh� eco Co L S 4 Vit' ' ( . (, 0 <br /> x <br /> All pertinent provisions and requirements of the prime contract including but not limited to Required Contract Total <br /> Provisions Federal-Aid Construction Contracts (FHWA-1273) and Special Provisions - Specific Equal Opportunity <br /> Responsibilities (Per 23 CFR-633B of Federal-Aid Policy Guide) will be part of the subcontract. It is agreed that an State of Florida <br /> pp <br /> Executed or a certified copy. of the subcontract will be submitted upon request, to the State of Florida Department of County Of �'Vtl.1 ,LLt <br /> V11,l�Ql � <br /> Transportation . All sublets will be in continued compliance with all Contract provisions and that the Contractor will <br /> continue to perform the minimum percentage of Contract work with its own organization , as required by said Sworn to and subscribed before <br /> me this est day <br /> Contract. It is recognized and agreed that, as prime contractor, the undersigned remains responsible for the proper <br /> performance of all requirements of said contract does not relieve or release the undersigned and his surety or either O k b t <br /> , by ( VIA <br /> of them of any liability under the contract bond . The Contractor shall send a copy of this form to the subcontractor/ ( Print name <br /> of person signing Certification ) <br /> 0 <br /> 0 subordinate (with a copy of FHWA-1273 on Federal-Aid Projects) and the Surety Company. The Prime certify that ��✓ � Y ' d <br /> L;1 firms or individuals , debarred or suspended by the FHWA or the Department, are not being used as subcontractors. <br /> 0 Notary Public <br /> 0 A false statement or omission made in connection with this certification is sufficient cause for suspension , � � � " t q��I P*4 VICf�E <br /> LEE WRIGHT* ofFl <br /> I t = * Notary Public • Shte of Florlra <br /> low revocation , or denial of qualification to bid, and a determination of non-responsibility, and may subject the person Commission Expires i <br /> , o * *„ My CommixWon Exp. Mamh 1112012 1 <br /> and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable Personally Known V OR ProduO <br /> a" 11 . ICatiodAftlmltilOtt * DD 75M I <br /> Federal and State Law. <br /> Type of Identification Produced <br />