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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 /> Date: General Info T?7t1 �otJS�RVCIto�J ,�N�. (Seal) <br /> Request No.- Prime Contractor Contractor <br /> FAP No.' <br /> By: <br /> Fin. Proj. ID: F.E.I.D. # IF CORPORATION,AFFIX SEAL <br /> Cont. No No.. ' <br /> Count : Il"]t1 1tiu�iQa Rt�et� T::;"r-- 1402-A <br /> Total Contract Amount Address <br /> JE�j �,a-c�t Ftr 32gco D <br /> Total Work <br /> 'L Subcontractor Name FEID# Subcontract to Whom Work Description ,: Total Amt in <br /> v' a Sublet <br /> .z <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-6336 of Federal-Aid Policy Guide)will be part of the subcontract. It is agreed that an State of Florida <br /> Executed or a certified copy of the subcontract will be submitted upon request,to the State of Florida Department of County of 1Al2)-1 1e,,V69(_ <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 me 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 of said contract does not relieve or release the undersigned and his surety or either of by <br /> O of them of any liability under the contract bond. The Contractor shall send a copy of this form to the subcontractor! Print name of person signing Certification) <br /> O subordinate(with a copy of FHWA-1273 on Federal-Aid Projects)and the Surety Company. The Prime certify that <br /> U1 firms or individuals,debarred or suspended by the FHWA or the Department,are not being used as subcontractors. -� �c7 +�:►9= <br /> +Etc MARION <br /> O Notary PublS _*; RNPEK <br /> I A false statement or omission made in connection with this certification is sufficient cause for suspension, —7 f0/ zc.) +, o" CMUSWN 2� <br /> O / �Z y <br /> N revocation,or denial of qualification to bid,and a determination of non-responsibility,and may subject the person Commission Expires °:€y°Q Bdtded �'un <br /> and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable Personally Known ✓ OR Produced Identifica to No�rrp � <br /> Federal and State Law <br /> Type of Identification Produced <br />