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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 Sworn Statement is submitted with Project No. 1619 for ROUND ISLAND <br /> RIVERSIDE PARK PAVEMENT RESURFACING. <br /> 2. This Sworn Statement is submitted by Community Asphalt,Corp. <br /> (Legal Name of Entity Submitting Sworn Statement) <br /> hereinafter "BIDDER". The BIDDER's address is <br /> 2975 Industrial Blvd.,Vero Beach,FL 32967 <br /> BIDDER's Federal Employer Identification Number(FEIN) is 59-2023298 <br /> 3. My name is Manuel Aguiar and my relationship to the BIDDER <br /> (Print Name of Individual Signing) <br /> is Vice President <br /> (Position or Title) <br /> I certify, through my signature at the end of this Sworn Statement, that I 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.seg. 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 /> BID-DER. 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$ , <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: <br /> The determination of the appropriate methods) of compliance is the complete and sole <br /> r9sponsibility 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 requirements by instituting the <br /> following specific method(s) of compliance on this Project: <br /> 14r <br /> 00454-Florida Trench Safety Act-REV 04-07 <br /> 00454-1 <br /> FAPublic WorksIENGINEERING DIVISION PROJECTSMIS Round Island FacilRy PavMgll-AdminWid dowmentslMaster contract DocumentsWD454-Florida Trench Safely <br /> Act.REV 04-07.doc <br />