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1 <br />SECTION 00454 = Sworn Statement Under the Florida Trench Safety Act <br />THIS FORM MUST BE SIGNED BY THE BIDDER WHO WILL BE RESPONSIBLE <br />FOR THE EXCAVATION WORK ("BIDDER"), OR ITS AUTHORIZED <br />REPRESENTATIVE, IN THE PRESENCE OF A NOTARY PUBLIC AUTHORIZED TO <br />ADMINISTER OATHS, <br />This Sworn Statement is submitted with Project No's. 0803, 0837. 0838 for Paving and <br />Avenue. <br />2. This Sworn Statement is submitted by J' w' ctt C4i a•wi , L L c. <br />I(Legal Name of Entity Submitting Sworn Statement) <br />hereinafter "BIDDER". The BIDDER's address is <br />I 73ti4 1 ab+pe•4 plats w• P• Q, PL• 331,13 <br />BIDDER's Federal Employer Identification Number (FEIN) is Zo 19z 3 4 7 ei <br />3. My name is S i 5; h • M o LA AA Ar of 1 and my relationship to the BIDDER <br />(Print Namel of Individual Signing) <br />111 IS k/ Cc <br />(Position or Title) <br />I certify, through my signature at the end of this Sworn Statement, that I am an <br />authorized representative of the BIDDER. <br />4, The Trench Safety Standards that will be in effect during the construction of this Project <br />are contained within the Trench Safety Act, Section 553.60 et.seq Florida Statutes and <br />refer to the applicable Florida Statue(s) and/or OSHA Regulation(s) and include the <br />"effective date" in the citation(s). Reference to and compliance with the applicable <br />Florida Statute(s) and OSHA Regulation(s) is the complete and sole responsibility of the <br />BIDDER. Such reference will not be checked by OWNER or ENGINEER and they shall <br />have no responsibility to review or check the BIDDER's compliance with the Trench <br />Safety Standards. <br />5. The BIDDER assures the OWNER that it will comply with the applicable Trench Safety <br />Standards, <br />6, The BIDDER has allocated and included in its bid the total amount of $ Z S13• ° a <br />based on the linear feet of trench to be excavated over five (5) feet deep, for compliance <br />with the applicable Trench Safety Standards, and intends to comply with said standards <br />by instituting the following specific method(s) of compliance on this Project: <br />cps >L <br />The determination of the appropriate method(s) of compliance is the complete and sole <br />responsibility of the BIDDER. Such methods will not be checked by the OWNER or <br />ENGINEER for accuracy, completeness, or any other purpose. The OWNER and <br />ENGINEER shall have no responsibility to review or check the BIDDER's compliance <br />with the Trench Safety Standards. <br />7) The BIDDER has allocated and included in its bid the total amount of $ ZSR' <br />based on the square feet of shoring to be used for compliance with shoring safety <br />requirements and intends to comply with said shoring requirements by instituting the <br />following specific method(s) of compliance on this Project: T�. k H a•� <br />00454-1 00454 - Florida Trench Safety Act - REV 04-07 <br />F:\Engineering\Capital Projects\0803 17th Lane SW Roadway Improvements from 27th Ave to approx. 900 LF east of 27th Ave\0803 Contract Documents\00454 - Florida <br />Trnn�h Qefehi AM . RFS/ n6.n7 Anr <br />