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a ,« <br /> a <br /> lig <br /> a <br /> 7V I:e <br /> _ STATE OF fLORIDA DEPARTMENT of TRANSPORTATION 70"10J8 <br /> CERTIFICATION OF SUBLET WORK CONSTRUCTION <br /> 10/07 <br /> TO: THE STATE OF FLOR A DEPARTMENT OF TRANSPORTATION ' <br /> Date: Q) "C l 12 General Info l Wtb Se CA ow+. 'tic.. (seal) <br /> Request No. : Prime Contractor ctor <br /> FAP No. : <br /> Fin. Proj. ID: IIIIII"I t VK °Al ` 1Z o 5e. Qn4l <br /> Cont. No. : <br /> F.E . I . D . # IF CORPORATION, SEAL <br /> Coun : )e ' =,00 �, 5 - oa8y � �} a 1360 � w l) tc� 1:) L e 1-{ &ILl\ , s4e <br /> 14) 1p <br /> Total Contract Amount Address <br /> Total Work �20jI qtr. ✓ z <br /> U.e, <br /> Total Amt <br /> Amt <br /> Vol <br /> Subcontractor Name FEID # Subcontract to Whom Work Description <br /> n:> Sublet g ;o; <br /> ts. :z <br /> S > cv�'�YLEt CO Sv . <br /> 1 iV�rf. <br /> All pertinent provisions and requirements of the prime contract including but not limited to Required Contract Total <br /> Provisions FederakMd Construction Contracts (FHWA4273) 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 1� <br /> Executed or a certified copy of the subcontract will be submitted upon request, to the State of Florida Department of County of ::r I E(U� <br /> {� w eyzao� <br /> Transportation. All sublets will be in continued compliance with sit Contract provisions and that the Contractor will 9 <br /> continue to perform the minimum percentage of Contract work with Its own organization, as required by said Sw to and subscribed before me <br /> this day <br /> Contract. It is recognized and agreed that, as prime contractor, the undersigned remains responsible for the proper <br /> performance of all requirements oftsaid contract does not relieve or release the undersigned and his surety or either f > Z , <br /> by 1 ) I;>6 s•e� <br /> of them of any liability under the contract bond. The Contractor shall send a copy of this form to the subcontractor/ .� (Print <br /> name of person signing Certification) <br /> p subordinate (with a copy of FHWA-1273 on Federal-Aid Projects) and the Surety Company. The Prime certify that <br /> lJt fines or individuals, debarred or suspended by the FHWA or the Department, are not being used as subcontractors. FE: <br /> p No ry bll VICKIE LEE WRIf3i4TI A false statement or omission made <br /> in connection with this certification Is sufficient cause for suspension, t � � m Nary P of Rgfldarevocation, or dental <br /> of qualification to bid, and a determination of non.responsibility, and may subject the person COmmissi0 ExpiresMy COmmist{I00 Exp. YIIrCA 11, 2016and/or entity <br /> making the false statement to any and ail civil and criminal penalties available pursuant to applicable personally Known Commissltln No. <br /> EE 171452 <br /> OR Produce <br /> Federal and State Law. <br /> Type of Identification Produced _ kS� - <br />