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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION 700-09036' <br /> CERTIFICATION OF SUBLET WORK y CONSTRUCTION <br /> 10A7 <br /> TO: THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br /> Date: , t General Info (Seal) <br /> Request No.: Prime Contractor Contractor <br /> FAP No.: �k-Q�,n <br /> Fin. Proj. ID: By' <br /> Cont. No,; SE•i•'DZ...# 2.._ IF„ ORATION,AFFIX SEAL <br /> Countv: r <br /> � via too <br /> Add ss <br /> Total Contract Total Workmount e\' � � �� (,2-- <br /> 4 u7 Q. <br /> ,C< <u 4r:: Total Amt m .m <br /> �' Subcontractor Name } FEID# Subcontract to Whom Work Description o z <br /> a: Sublet o; <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-6338 of Federal-Aid Policy Guide)will be part of the subcontract. It is agreed that an State of Flori�d�a,J <br /> Executed or a certified copy of the subcontract will be submitted upon request,to the State of Florida Department of County of I LO n( � <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 Swam to and s bscribed before me this1 d y <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 0 <br /> of them of any liability under the contract bond. The Contractor shall send a copy of this form to the subcontractor/ (Print name of&sbn signing Certificatio _ <br /> subordinate(with a copy of FHWA-1273 on Federal-Aid Projects)and the Surety Company. The Prime certify that �y. <br /> Ln firms or Individuals,debarred or suspended by the FHWA or the Department,are not being used as subcontractors. NOt UbUC DEB() <br /> WEST <br /> pG 3 MY COMMISSION#FF904M <br /> I A false statement or omission made in connection with this certification is sufficient cause for suspension, f WIRES:Octobtr 03,2014 <br /> EQ revocation,or denial of qualification to bid,and a determination of non-responsibility,and may subject the person Commission Expires <br /> and/or entity making the(else statement to any and all civil and criminal penalties available pursuant to applicable <br /> Personally Known OR Produced identification <br /> Federal and State Law. <br /> Type of Identificatia Produced <br />