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i 4D i SWORN STATEMENT UNDER THE FLORIDA TRENCH SAFETY ACT THIS FORIM MUST BE SIGNED I3Y THE BIDDER WHO WILL BE RESPONSIBLE FOR ! THE EXCAVA'T'ION WORK ("BIDDER"), OR ITS AUTHORIZED REPRESENTATIVE, INTHE PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO ADKINISTER OATHS. 1. This Sworn Statement is submitted with the Bid No. _._ 202G - for �s 4baS5� C]rl7VrntS (Name or Project, and Contract No. or Designadon, etre.) � 2, This Sworn Statement is submitted by William Glover, Inc. (regai name oren6ty submitting sworn statement) 1 hereinafter "BIDDER",business address is 286 North Babcock St., Melbourne, Fl. 32935 t BIDDER'S Federal Employer Identification Number (FEIN} is 59-2300274 " William Glover ' 3. My name is and my relationship (print name o r ind iv'sdu al 'signing) to the BIDDER is president — of/for the l-3LDDER William Glover, Inc. _ (position or title) I certify, through my signature at the end of this Sworn Statement, that I am art authorized representative of the BIDDER. 4, The Trench Safety Standards that will be in effect during the construction of this Project are contained within A.WeJ t v, 4vevinis-' & " (refer to the applicable Florida Statute(s) and/or OSIiA Regulation(s) and include the ""effective date" in the citation(s). Reference to and compliance with the applicable Florida Statute(s) and/or OSTIA Regulation(s) is the complete and sole responsibility of the BIDDER. Such reference will not be checked by OWNER or ENGINEER for accuracy, completeness or any other purpose. The OWNER and ENGINEER shall have no responsibility to review or check the BTDDEWS compliance with the trench safety standards. 5. I'lte BIDDER assures the OWNER that it will comply with the applicable Trench Safety Standards and agrees to indemnify, defend and hold harmless the OWNER and ENGINEER, and any of their agents or employees, from any claims arising from the failure of the BIDDER to identify applicable standards or to comply with said standards. As specific . consideration for the indemnification above, the OWNER agrees to give the BIDDER twenty-five dollars ($25.00), which the OWNER agrees is paid on behalf of all parties ;adcmnified ltt:i-eras aL:svt-, 6. The BIDDER has allocated and included in its bid the total amount ofS5Q'Ly^ , based ' on the linear feet of trench to be excavated over five (5) feet deep, for compliance with the applicable Trench Safety Standards and intends to comply with said standards by instructing the following specific method(s) of compliance on this Project: Tin r ,a ! yt i•r aont� tg� _5 c ewtfs c7 V The determination of the appropriate method(s) of compliance is the complete and sole responsibility of the BIDDER. Such ructhods will not be checked by the OWNER or ENGINEER for accuracy, completeness or any other purpose. The OWNER and TPUNCH STATEMENT