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C: THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br />vz, art <br />TiII 05`i <br />.13111111118 <br />STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br />CERTIFICATION OF SUBLET WORK <br />700-010.3a <br />CONSTRUCTION <br />10/07 <br />Date: ri (, ),1 4.1, <br />--71 <br />General Info <br />I ( n ,fit 01-741(Seal) <br />Request No.: i <br />�t��U� <br />Prime Contractortr� <br />r <br />jj Contractor d <br />B y� <br />FAP No.: _2-J -t�/ <br />r' -CJ <br />ID <br />Fin. Proj. ID: "- <br />F.E.I.D. # <br />IF CORPORATION, AFFiX SEAL <br />/360Svt / O Id 1v t_c- it/i,Si'uii..) Pa: <br />Cont. No.: <br />Co- O2_8 (-/Z(IZ <br />County: i rY_b.4ri River <br />Total Contract Amount <br />n Address <br />U ( 3Z`�(-� <br />Total Work <br />i?9,Z00.`'2 <br />,ii, <br />Subcontractor Name <br />'S..�;� <br />FEID # <br />Subcontract to Whom <br />Work Description,: <br />a.. <br />Total Amt <br />Sublet <br />ili. <br />�::_ <br />0. :o;• <br />.z <br />ttipkx,e:1 <br />Qo -Uri 3031v <br />-ri,o e,,rvi, <br />N <br />1 <br />All pertinent provisions and requirements of the prime cont act including but not limited to Required Contract <br />Provisions Federal -Aid Construction Contracts (FHWA-1273) and Special Provisions - Specific Eoual O000rtunity <br />Total <br />Responsibilities (Per 23 CFR -633B of Federal-Ald Policy Guide) will 'be part of the subcontract. It is agreed that an <br />Executed or a certified copy of the subcontract will be submitted upon request, to the State of Flbrida Department of <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 <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 <br />of them of any liability under the contract bond. The Contractor shall send a copy of this form to the subcontractor/ <br />subordinate (with a copy of FHWA-1273'on Federal -Aid Projects) and the Surety Company. The'Prime certify that <br />firms or individuals, debarred or suspended by the FHWA.or the Department, are not being used as subcontractors. <br />A false statement or omission made in connection with this certification is sufficient cause for suspension. <br />revocation, or denial of qualification to bid, and a determination of non -responsibility, and may subject the person <br />and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable <br />Federal and State Law. <br />State of Florida <br />County of j -Nr ).n'kuje/ <br />Sworn to and subscribed before me this t j day <br />of <br />NoV <br />ZO , by.C1i <br />(PrintTname of pp son signing Certification) <br />Not <br />Public <br />Commission Expires <br />Personally Known <br />.ocr 03, 2015 <br />ieeosoormy FL Nowa, Ditemst <br />OR Produce <br />Type of Identification Produced <br />