12-Form - Trench Safety.pdf

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.

for .

2. This Sworn Statement is submitted by _______________________________________ (Legal Name of Entity Submitting Sworn Statement)

_____________________________________________________________, hereinafter “BIDDER”. The BIDDER’s address is

BIDDER’s Federal Employer Identification Number (FEIN) is .

3. My name is ________________________________ and my relationship to the BIDDER

(Print Name of Individual Signing) is ______________________________________________________________.

(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.seq. 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 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 $_____________, 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: __________

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.

7. The BIDDER has allocated and included in its bid the total amount of $______________ based on the square feet of shoring to be used for compliance with shoring safety requirements and intends to comply with said shoring requirements by instituting the following specific method(s) of compliance on this Project: _______________________

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.

8. The BIDDER, in submitting this bid, represents that it has obtained and considered all available geotechnical information, has utilized said geotechnical information and that, based on such information and the BIDDER’s own information, the BIDDER has sufficient knowledge of the Project’s surface and subsurface site conditions and characteristics to assure BIDDER’s compliance with the applicable Trench Safety Standards in designing the trench safety system(s) for the Project.

BIDDER: _________________________________

By: _____________________________________

Position or Title: ___________________________ Date: ____________________________________

STATE OF

COUNTY OF

Sworn to (or affirmed) and subscribed before me by means of ☐ physical presence or ☐ online notarization, this day of ____________________, 20 , by

(name of person making statement).

(Signature of Notary Public - State of Florida) (Print, Type, or Stamp Commissioned Name of Notary Public)

☐ who is personally known to me or ☐ who has produced ______________________________ as identification.

* * END OF SECTION * *

Sworn Statement Under the Florida Trench Safety Act