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211 :10 Q7 • SWORN STATEMENT CINDER THE FLORIDA TRENCH SAFETY ACT THIS FORM MUST BE SIGNED BY THE BIDDER 141I0 WILL BE RESPONSIBLE FOR THE EXCAVATION WORK ("BIDDER"), OR ITS AUT,"ORIZE:D REPRESENTATIVE, IN THE PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO AllNHNISTF.R OATHS. I . This Swom Statement is submitted with the }aid No. --2f150_ for uildines (\anx orhrojcct, and Cosnvut No or rxsigntnon, etc) 2. This Sworn Statement is submitted by —William Glover, Inc, (Testl name dfentiry submining swam smemmi) Ihereinafter "BIDDER",business address is 286 Nortli BabovA St., Melbourne, Florida 32935 BIDDER'S Federal Employer Identification Number (FErN) is 59-23M74 3. My name is William Gt_over and my relationship (pnn° nsm or%rd+nduai signing) to the BIDDER is President of/for the BIDDER William Glover, Inc, (position or title) I certify, through my signature at the end of this Sworn Statement, that I am an authorized representative of the BIDDER. 4. The Trench Safety Standards that will be in effect during the construction of this Project are contained within _ N/A (refer to the applicable Florida Statute(s) andlor OSHA Regulation(s) and include the "effective date" in the citation(s). Deference to and compliance with the applicable Florida Statute(s) and/or OSHA 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 Iresponsibility to review or check the BIDDER'S compliance with the trench safety standards. 5. The BIDDER assures the OWNER that it will comply with the applicable Trench Safety Standards and agrees to indernnify, defend and hold harmless the OWNER and ENGi\rEER, 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 (S25.00), which the OWNER agrees is paid on behalf of all panics indemnified herein above. b. The BIDDER has allocated and included in its bid the total amount of S _. based ° on the linear feta 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: The determination of the appropriate method(s) of compliance is the complete 4W sola responsibility of the BIDDER. Such methods will not be checked by the OWNER or dw ENGINEER lire accutUy. complvtensas err any other purixrse The OWNER and' t1t€WH S7�tvwtxt f.r