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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. 1024 for Indian River Blvd. & 17'h <br />St, Intersection Improvements. <br />2. This Sworn Statement is submitted by 1 Vyly� ��_u,b SA. <br />^l (Lega[Narriejo Entity $ubmittjrlg Sworn Statement) <br />J 1 it �L-.�-1rVb <br />hereinafter "BIDDER" J <br />S -I The I DER's address is <br />b S�cVr \ c f ' act,c <br />BIDDER's Federal Employer Identif ation Number (FEIN) is <br />3. My name is V" � � S and my relationship to the BIDDER <br />(Print Namq of Individual Signing) <br />Is tr2 P's \ 4 UV: <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.seg. 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 comoly with the anolicable Trench Safety <br />Standards, <br />6. The BIDDER has allocated and included in its bid the total amount of $ <br />based on the linear feet of trench to be excavated over five (5) feet deep, for 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: <br />The determination of the appropriate method(s) <br />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 $ iGr <br />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 _ n this Project: <br />00454 -Florida Trench Safety Act -REV 04-07.doc <br />00454 - 1 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS11024-17th Slreel and IR Blvd Inlerseclion\Admim\Contract Documents\00454 -Florida Trench Safely Act -REV 04- <br />07.doc <br />