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11111111110 <br />4a <br />0 <br />0 <br />SWORN STATEMENT UNDER THE FLORIDA <br />TRENCH SAFETY ACT <br />THIS FORM MUST BE SIGNED BY THE BIDDER WHO WILL BE RESPONSIBLE FOR THE <br />EXCAVATION WORK ('BIDDER"), OR ITS AUTHORIZED REPRESENTATIVE, IN THE <br />PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO ADMINISTER OATHS. <br />1. This Sworn Statement is submitted with the -Bid No: �L"of <br />(Narne of Project, and contract NO. or Designation, etc.) <br />2. This Sworn Statement is submitted by t <br />(legal name or entity oubmMing sevum statement) <br />hereinafter "BIDDER", business address is 'r` <br />BIDDER'S Federal Employer Identification Number (FEIN) is <br />3. My name is r,e— .�r r'r + tr a , t _ and my relationship (— 1`( r 'c V E �� <br />(printname of Individual signing) <br />to the BIDDER is 1r ' ,r. t', L�� of/for the BIDDER Cke -' „, �''�� I <br />( A (position or title) <br />I certify, through my signature at the end of this Sworn Statement, that I am an authorized <br />representative of the BIDDER. <br />4. The Trench Safety Stand ds that will be in effect during the construction of this Project <br />are contained within N f1 <br />(refer to the applicable iorida Statute(s) and/or OSHA Regulation(s) and include the <br />"effective date" in the citation(s), Reference to and compliance with the applicable Florida <br />Statute(s) and/or OSHA Regulation(s) is the complete and sole responsibility of the <br />BIDDER. Such reference will not be checked by OWNER or ENGINEER for accuracy, <br />completeness or any other purpose. The OWNER and ENGINEER shall have no <br />responsibility to review or check the BIDDER'S compliance with the trench safety <br />standards. <br />5. The BIDDER assures the OWNER that it will comply with the applicable Trench Safety <br />Standards and agrees to indemnify, defend and hold harmless the OWNER and <br />ENGINEER, and any of their agents or employees, from any claims arising from the failure <br />of the BIDDER to identify applicable standards or to comply with said standards. As <br />specific consideration for the indemnification above, the OWNER agrees to give the <br />BIDDER twenty-five dollars ($25.00), which the OWNER agrees is paid on behalf of all <br />parties indemnified herein above. <br />6. The BIDDER has allocated and included in its bid the total amount of $ h/ rl based <br />on the linear feet of trench to be excavated over five (5) feat deep, for comp/ ante with the <br />I <br />ITPPP-11 FTATEMENT <br />