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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
<br />CERTIFICATION OF SUBLET WORK
<br />TO: THE STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
<br />700-010-36
<br />CONSTRUCTION
<br />10107
<br />Date: is442p, 2ao5-
<br />General Info
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<br />Request No.:
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<br />Prime Contractor
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<br />FAP No.:
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<br />Cont. No.:
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<br />Total Contract Amount
<br />Address
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<br />Subcontractor Name
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<br />Subcontract to Whom
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<br />All pertinent provisions and requirements of the prime contract Including but not limited to Required Contract
<br />D.w..:_i.__ c_J..�., Ata n....b••..uw. PnnL...nb. /CLJ1MA 4o7�s �.a cs..r.,r o.,...rer....� _ c...,.ta„ c....,i n..,...a.,..u„
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<br />Responsibilities (Per 23 CFR -6338 of Federal -Aid Policy Guide) will be part of the subcontract, It is agreed that an
<br />Executed or a certified copy of the subcontract will be submitted upon request, to the State of Florida Department of
<br />Transportation. All sublets will be in continued compliance with all Contract provisions and that the Contractor will
<br />continue to perform the minimum percentage of Contract work with its own organization, as required by said
<br />Contract. It is recognized and agreed that, as prime contractor, the undersigned remains responsible for the proper
<br />performance of all requirements of said contract does not relieve or release the undersigned and his surety or either
<br />of them of any liability under the contract bond. The Contractor shall send a copy of this form to the subcontractor/
<br />subordinate (with a copy of FHWA-1273 on Federal Aid Protects) and the Surety Company, The Prime certify that
<br />firms or individuals, debarred or suspended by the FHWA or the Department, are not being used as subcontractors.
<br />A false statement or omission made in connection with this certification Is sufficient cause for suspension,
<br />revocation, or denial of qualification 10 bid, and a determination of non -responsibility, and may subject the person
<br />and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable
<br />Federal and State Law.
<br />State of Florida
<br />County of ,r. Lue__ e_.
<br />Sworn to and subscribed before me this a.0- day
<br />of ( , a.O t5 , by [kw le \ riusdh,&) e.
<br />.. L�.i.�/, r ' °""'"kt, JULIE J. GU TTLER
<br />. ry Publ c � MY COMMISSION # EE142573
<br />r J „ r 1 `�) `� 1) l� EXPIRES: October 31, 2015
<br />l �I�. � 'M1FI. Naary Discount Assoc. Co.
<br />1-8p0.1NOTARY
<br />Commission Expires
<br />Personally Known k OR Produced Identification
<br />Type of Identification Produced
<br />E)
<br />
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