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0 <br />e <br />0 <br />0 <br />a <br />1 <br />0 <br />9 <br />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 Swom Statement Is submitted with Project No. 0530B for <br />(1301 Street S.W. at 58"' Avenue Bridge) <br />2. This Swom Statement is submitted by Dickerson Florida, Inc. <br />(Legal Name of Entity Submitting Sworn Statement) <br />hereinafter "BIDDER'. The BIDDER's address Is <br />3122 N. 25th St., Ft. Pierce, FL 34946 <br />BIDDER's Federal Employer Identification Number (FEIN) is 5 6 -13 2 7 5 0 9 <br />3. My name is <br />is <br />Larry T. Dale <br />PresNacmenindividuat Signing) <br />and my relationship to the BIDDER <br />(Position or Title) <br />I certify, through my signature at the end of this Swom Statement, that 1 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.sea. 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 comply with the applicable Trench Safety <br />Standards. <br />6. The BIDDER has allocated and included In its bid the total amount of $ (o' ' Go <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: SLOPE - <br />The determination of the appropriate method(s) 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 $ <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 requirement y instituting the <br />following specific method(s) of compliance on this Project /V� <br />00454 - ' <br />F:' PidDIVISIONDSION PROJECT/11053M 1391 Street SW atAve <br />5SIh A <br />Safety A4 - REV O4.W.doe BrldpW Wldrllbid doameldaVNmRrCannelCacl Dooapan1a100154 . Florida Trench <br />00454 - Florida Trench Safety Act - REV 04-07.doc <br />