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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 /> 1 . This Sworn Statement is submitted with Project No 's . 0803 , 0837 , 0838 for Paving and <br /> Drainage Improvements to 17th Lane SW from 27th Avenue to East approx. 900 ' 20t Avenue <br /> from 21 st Street SW to 17th Lane SW and 17th Lane from Falcon Trace Proiect Entrance to 20t5 <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 '73 {14 1 ab+ pe • 4 VIco. w • P • Q, F: L& 33 ,113 <br /> BIDDER's Federal Employer Identification Number ( FEIN ) is Zo 19z 3 4 7 y <br /> 3 . My name is s i 5; h • 1 .10 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 />