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r r SECTION 00454 - Sworn Statement Under the Florida Trench Safety Act THIS FORM MUST BE SIGNED BY THE BIDDER WHO WILL BE RESPONSIBLE FOR THE EXCAVATION WORK ("BIDDER") , OR ITS AUTHORIZED • REPRESENTATIVE, IN THE PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO ADMINISTER OATHS . 1 . This Sworn Statement is submitted with Project No. 0201 for INDIAN RIVER DRIVE SOUTH SIDEWALK IMPROVEMENTS (Name of Project) 2 . This Sworn Statement is submitted by 1 Ctrtvty r c. _ �, D e rA 6 ") K\ (Legal Name of Entity Submitting Sworn Statement) hereinafter IfBIDDER" . The BIDDER's address is x300 Ay � C , oAp AUe_ r ft', -e- ADD I �7L �3a 9 3 9 - BIDDER s Federal Employer Identification Number ( FEW) is _.SJ - 39 -? y o so r 3 . My name is LaLu ( Lnu- -TCUAAf r Tr . and my relationship to the BIDDER (Pnnt, Name of Individual Signing) is eSI itis (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 the Trench Safety Act, Section 553. 60 et sep Florida Statutes and refer to the applicable Florida Statue(s) and/or OSHA Regulation (s) and include the "effective date" in the citation(s) . Reference to and compliance with the applicable Florida Statute (s) and OSHA Regulation(s) is the complete and sole responsibility of the BIDDER . Such reference will not be checked by OWNER or ENGINEER and they shall r have no responsibility 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. 6 . The BIDDER has allocated and included in its bid the total amount of $ I DOD . 00 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 instituting the following specific method(s) of compliance on this Project: - itoDo , ot) _ 5 : nc_t.uet;- � r ( evtt na- i r In r� w� L' F ( fatn b � Ux jl ) NIkL. j � Sr rill 5 — t{ S — � r The determination of the appropriate method (s) of compliance is the complete and sole responsibility of the BIDDER. Such methods will not be checked by the OWNER or ENGINEER for accuracy, completeness , or any other purpose . The OWNER and ENGINEER shall have no responsibility to review or check the BIDDER's compliance with the Trench Safety Standards . r r r 00454 - 1 0201 -00454 - Florida Trench Safety Act FAEngineeringlCaplou Pr01ectSW201-03128-Intlian River Drive Sitlev,alk-South-Highiancl Drive SW10201 Indian River Drive South Sidewalk - Contract DoMQ201 -00454 - Flunda Trench Safely Act,doa Rev. ovol