Project_Forms_Combined.pdf

PROJECT FORMS

ARTICLE 1 - INSTRUCTIONS

1.1. The following forms and certificates are samples of those to be used by the Contractor for submissions for Contractual and administrative requirements.

1.2. Requirements and instructions on the forms constitute extensions of, or additions to, the Contractual conditions of the Contract and the general requirements of the specification.

1.3. Do not detach, or otherwise remove sample project forms from specifications.

1.4. Prepare all forms as required with all blank spaces filled in, in ink or typewritten.

1.5 Submit all Forms to the Office of the County Engineer

ARTICLE 2 - PROJECT FORM LISTING

Part 1: Standard Contract Administration Forms

Application and Certificate for Payment (Prepared and submitted by prime contractor monthly for progress payment)

Continuation Sheet (Prepared and submitted by prime contractor as itemized breakdown of monthly progress payment)

Agreement Amendment (Prepared by Engineer for contract revision)

Contractor's Affidavit for Payment of Debts and Claims (Prepared and submitted by prime contractor as part of project close-out documentation to be accompanied by separate release or waivers of lien from sub-contractors and material and equipment suppliers)

Contractor's Affidavit of Release of Liens (Final Release) (Prepared and submitted by prime contractor as part of project close-out documentation)

Consent of Surety Company To Final Payment (Prepared and submitted by prime contractor as part of project close-out documentation)

Partial Release of Lien (Submitted monthly by prime contractor with each invoice beginning with the second progress payment application)

Conditional Final Release and Waiver of Lien (Prepared and submitted by prime contractor as part of project close-out documentation)

Final Release of Lien (Prepared and submitted by prime contractor as part of project close-out documentation)

Certificate of Substantial Completion (Prepared by Engineer)

Certificate of Final Completion (Prepared by Engineer)

Part 2: FDOT Program Forms:

*Note: Many of the forms listed below are available from FDOT in excel, word or other fillable formats and can be downloaded at: https://www.fdot.gov/construction/forms/FormsMain.shtm

Certification Disbursement of Previous Periodic Payment to Subcontractors (FDOT Form 700-010-38) (Submitted monthly by prime contractor with each invoice beginning with the second progress payment application)

Construction Compliance with Specifications and Plans (FDOT Form 700-020-02) (Submitted monthly by prime contractor with each invoice)

Maintenance of Traffic (MOT) Review Report (FDOT Form 700-011-37) (Submitted by the prime contractor after initial commencement of MOT activities and weekly thereafter until completed)

Part 3: Miscellaneous Forms:

Stormwater Pollution Prevention Plan Inspection and Maintenance Report (Submitted by the prime contractor after the commencement of earth disturbing activities and weekly and within 24 hours of the end of a storm that is 0.50 inches or greater amount)

PAYMENT APPLICATION FORM

FLAGLER COUNTY

APPLICATION No.: _____

CONTRACTOR: _____________________________ ENGINEER: Flagler County Engineering Dept.

(Address:)

Bunnell, Florida 32110

ORIGINAL CONTRACT SUM $

NET REVISIONS $

CONTRACT SUM TO DATE $

TOTAL COMPLETE TO DATE $

Less: Retainage $

EARNED LESS RETAINAGE $

PAYMENT FOR STORED MATERIALS $

TOTAL LESS RETAINAGE $

TOTAL REVISIONS LESS PREVIOUS PAYMENTS MADE $

NET REVISIONS: $______________________ AMOUNT DUE THIS APPLICATION $_______________________

CONTRACTOR:______________________________

BY:

SIGNED:

NOTARY PUBLIC:

DATE: ______________ MY COMMISSION EXPIRES: _______________

RECOMMENDED FOR ACCEPTANCE AND PAYMENT:

DATE: _______________ COUNTY ENGINEER:

1769 E. Moody Blvd. Bldg. 2

CHANGE ORDER

No._____ Approval

DATE

FOR PAYMENT - Project Name and Number

Payment in the amount shown is due for work performed during the period of _________ thru ________, as detail on the attached Schedule of Payments. The present status of the Account for this Contract is :

The undersigned certifies that the Work covered by this Application for Payment has been completed in accordance with the Contract Documents and/or any Amendments thereto, that all amounts due Subcontractors and Suppliers for Work, for which previous Applications for Payment were issued and payment has been received from Flagler County, has been paid by him; that all Subcontractors and Suppliers have issued Releases of Lien (copy attached) and the current payment shown herein is now due.

Subscribed & Sworn to before me this ____day of

First Avenue Drainage Improvements Phase 2 Number____________________

ADDITION DEDUCTION

AMENDMENTS TO CONTRACT PAYMENT DUE THIS APPLICATION

APPLICATION FOR PAYMENT CONTINUATION FORM

FLAGLER COUNTY - CONTRACTOR'S APPLICATION FOR PAYMENT - SHEET ______ OF ______

PROJ. NO.: ____________ SCHEDULE:

COVERING PERIOD: THRU

APPLICATION No. DATE: BY: REVIEWED BY:

NO. PREVIOUS TOTAL THIS PERIOD TOTAL TO DATE PREVIOUS TOTAL THIS PERIOD TOTAL TO DATE

ITEM

DESCRIPTION

CONTRACT

QUANTITY UNIT

PROJECT NAME:

FIRST AVENUE DRAINAGE IMPROVEMENTS

PROJECT - PHASE 2

CONTRACTOR:

UNIT

PRICE

QUANTITY INSTALLED & COMPLETE DOLLAR AMOUNT

(Page 1 of 3)

AMENDMENT TO AN AGREEMENT

BETWEEN FLAGLER COUNTY

AND

_____________________________(Contractor)

FOR

First Avenue Drainage Improvements, Phase 2

County Project No. ____________

Flagler County, Florida, a political subdivision (COUNTY) and (CONTRACTOR) hereby enter into this Amendment to the Agreement executed on .

WHEREAS, COUNTY AND CONTRACTOR have entered into an Agreement for on , .

WHEREAS, the PARTIES have entered into a Amendment on , for the purpose of:

1. The ending date for the AGREEMENT subsequent to this Amendment.

2. All Terms and Conditions of the original Contract and any subsequent amendments thereto shall remain unmodified and shall remain in full force and effect.

3. This Amendment must be accepted by the CONTRACTOR and Contract Surety and must be approved by the Flagler County Board of County Commissioners to become effective.

AMOUNT TIME

Original Contract Agreement........................................... $ _____________

CHANGES BY PREVIOUS AMENDMENTS:

NO. DATE APPROVED

TOTAL CHANGES BY AMENDMENT NO. thru $

TOTAL CONTRACT prior to this Amendment (No. )........................$

TOTAL This Amendment..........................................................................$

NEW CONTRACT (All Amendments)...................................................... $

(Page 2 of 3)

ACCEPTANCE: (CONTRACTOR)

I (We) agree to this Amendment No. __ for the amount and within the time allocated all in accordance with Contract Plans, Specifications and related Documents.

WITNESS: NAME: __________________________________________

(Signature)

BY: DATE:

(Typed or Printed) (Signature)

WITNESS:

(Signature) (Typed/Printed Name & Title)

(Typed or Printed)

SURETY

I (We) have reviewed the foregoing Contract and Amendment and have adjusted the Contract Sureties to Conform with this Amendment.

SURETY:

BY: DATE:

(Signature)

(Typed/Printed Name & Title) (Agent-In-Fact Certification Attached)

RECOMMENDED BY: RECOMMENDED BY:

Flagler County Engineering Dept.

(Signature)

(Date) (Date)

(Typed/Printed Name & Title)

APPROVED AS TO FORM:

Flagler County Legal Dept.

(Date)

(Page 3 of 3)

APPROVED: FLAGLER COUNTY

BY: _____________________________

Adam Mengel, County Administrator

(Date)

CONTRACTOR’S OWNER

AFFIDAVIT OF ENGINEER

PAYMENT OF CONTRACTOR

DEBTS AND CLAIMS SURETY

OTHER

TO: (OWNER): FLAGLER COUNTY ENGINEER’ PROJECT NO.:

BOARD OF COUNTY COMMISSIONERS

CONTRACT FOR PROJECT: First Avenue Drainage Improvements Project, Phase 2

(NAME, ADDRESS) CONTRACT DATE: _______________________________________

STATE OF: _________________________

COUNTY OF: _______________________

The undersigned, pursuant to the Standard Conditions of the Contract for Construction, hereby certifies that, except as listed below, he has paid in full or has otherwise satisfied all obligations for all materials and equipment furnished, for all work, labor, and services performed, and for all known indebtedness and claims against the Contractor for damages arising in any manner in connection with the performance of the Contract referenced above for which the Owner or his property might in any way be held responsible.

EXCEPTIONS: (If none, write “NONE”. If required by the Owner, the Contractor shall furnish bond satisfactory to the Owner for each exception).

SUPPORTING DOCUMENTS ATTACHED HERETO: CONTRACTOR:____________________________

1. Consent of Surety to Final Payment, Whenever Surety is involved

Consent of Surety is required. ADDRESS:_________________________________

Indicate attachments (YES___) (NO ____)

The following supporting documents should be attached hereto if required by the OWNER. BY: ______________________________________

1. Contractor’s Release or Waiver of Liens, conditional upon receipt of Final Payment. Subscribed and Sworn to before me this _____ Day of _________, 20__

2. Separate Release or Waivers of Leans from Sub-contractors and material and equipment suppliers to the extent required by the Owner, accomplished by a list thereof. NOTARY PUBLIC: ______________________

3. Contractor’s Affidavit of Release of Liens My Commission Expires:________________

CONTRACTOR’S OWNER

AFFIDAVIT OF ENGINEER

RELEASE OF LIENS CONTRACTOR

TO: (OWNER) FLAGLER COUNTY ENGINEER’ PROJECT NO.:

(NAME, ADDRESS) CONTRACT DATE:_______________________________________

The undersigned, pursuant to the Standard General Conditions of the Contract for Construction, hereby certifies that all Contractors, all Sub-contractors, all suppliers of material and equipment and all performers of work, labor or services who have or may have liens against any property of the Owner arising in any manner out of the performance of the Contact referenced above have been paid in full.

EXCEPTION: (If none, write “NONE”. If required by the Owner, the Contractor shall furnish bond satisfactory to the Owner for each exception).

SUPPORTING DOCUMENTS ATTACHED HERETO: CONTRACTOR: ___________________________

1. Contractor’s Release or Waiver of Liens, conditional upon receipt ADDRESS:_________________________________ of Final Payment. _________________________________

2. Separate Release or Waivers of Liens from Sub-contractors and equipment suppliers, to the extent required by the Owner, accompanied by a list thereof. BY: _______________________________________

Subscribed and Sworn to before me this ______Day of _____________, 20___

NOTARY PUBLIC:______________________________

My Commission Expires:___________________________

CONSENT OF OWNER

SURETY COMPANY ENGINEER

TO FINAL PAYMENT CONTRACTOR

TO: (OWNER) ENGINEER’S PROJECT NO.:

CONTRACTOR:

(NAME, ADDRESS) CONTRACT DATE:_______________________________________

In accordance with the provisions of the Contract between the Owner and the Contractor as indicated above, the (Insert Name and Address of Surety Company)

SURETY COMPANY:

On Bond of (Insert Name and Address of Contractor)

CONTRACTOR:

Hereby approves of the Final Payment to the Contractor, and agrees that Final Payment to the Contractor shall not relieve the Surety Company of any of its obligations to (Insert Name and Address of Owner).

OWNER: FLAGLER COUNTY BOARD OF COUNTY COMMISSIONERS, 1769 E. MOODY BOULEVARD, BUILDING NO. 2, BUNNELL, FLORIDA 32110

As set for in the said Surety Company’s Bond.

IN WITNESS WHEREOF,

the Surety Company has hereunto set its hand the _______Day of _______________________, _______.

SURETY COMPANY

ATTEST: ________________________________________________

(SEAL) SIGNATURE OF AUTHORIZED REPRESENTATIVE

TITLE

WAIVER AND RELEASE OF LIEN

UPON PROGRESS PAYMENT

“PARTIAL RELEASE OF LIEN”

The undersigned Lienor, in consideration of $____________________________________, ____________________________________hereby waives and releases its lien and right to

(COMPANY/CONTRACTOR)

claim a lien for labor, services, or materials furnished through ____________ to _____________

(DATE) (DATE)

to the Flagler County Board of County Commissioners on the job of FIRST AVENUE DRAINAGE IMPROVEMENTS PROJECT, PHASE 2, PROJECT NO:_________to the following described property:

ROADWAY AND RELATED IMPROVEMENTS

COUNTY ROAD 205 Right of Way, Flagler County, Florida

This waiver and release does not cover any retention or labor, services, or materials furnished after the date specified.

This Partial Release is furnished in accordance with 713.2(3), Florida Statutes.

DATED on _______________________, 20 ____

By:___________________________________ (Signature of Lienor)

(Printed Name & Title)

Lienor’s Name and Address: __________________________________________________

STATE OF FLORIDA

COUNTY OF ____________

Sworn to (or affirmed) and subscribed before me this ________ day of _____________, 20___ by ____________________________________.

SIGNATURE OF NOTARY PUBLIC

Print, Type or Stamp Commissioned Name

Personally Known ______________ OR Produced Identification _____________

Type of Identification Produced ___________________________________

CONDITIONAL FINAL RELEASE AND WAIVER OF LIEN

The undersigned lienor, in consideration of $________________________, hereby waives and releases its lien and right to claim a lien for labor, services, or materials furnished through _________, 20___ to _______, 20___ to the Flagler County Board of County Commissioners on the job of FIRST AVENUE DRAINAGE IMPROVEMENTS PROJECT, PHASE 2, PROJECT NO: ITB___________, to the following described property:

ROADWAY AND RELATED IMPROVEMENTS

FIRST AVENUE Right of Way, Flagler County, Florida

This undersigned certifies that all labor, services, and/or materials described herein have been provided to the execution and delivery of this document.

The Conditional Final Release and Lien Waiver is conditioned upon the undersigned receiving $____________________ for the work described in this Release and Waiver.

The Conditional Final Release is furnished in accordance with 713.20, Florida Statutes.

DATED on ________, _______________, 20 ____

By:____________________________________________

(Printed Name & Title)

Lienor’s Name and Address: ______________________________________________________

STATE OF FLORIDA

COUNTY OF ____________

Print, Type or Stamp Commissioned Name

Personally Known ______________ OR Produced Identification ___________________

WAIVER AND RELEASE OF LIEN

UPON FINAL PAYMENT

The undersigned lienor, in consideration of the final payment in the amount of $________________________, hereby waives and releases its lien and right to claim a lien for labor, services, or materials furnished to the Flagler County Board of County Commissioners on the job of FIRST AVENUE DRAINAGE IMPROVEMENTS PROJECT, PHASE 2, PROJECT NO: ________ to the following described property:

ROADWAY AND RELATED IMPROVEMENTS_

COUNTY ROAD 205 Right of Way, Flagler County, Florida

This Final Release is furnished in accordance with 713.2(5), Florida Statutes.

DATED on ________, _______________, 20 ____

By:___________________________________

(Printed Name & Title)

Lienor’s Name and Address: _____________________________________________

STATE OF FLORIDA

COUNTY OF ____________

Print, Type or Stamp Commissioned Name

Personally Known ______________ OR Produced Identification ______________

(1 of 2)

CERTIFICATE OF SUBSTANTIAL COMPLETION

PROJECT: FIRST AVENUE DRAINAGE IMPROVEMENTS PROJECT, PHASE 2

CONTRACT DATE:______________

COUNTY PROJECT NO.: ______________

This Certificate of Substantial Completion applies to:

_____ All work under Contract _____ Portion of work described as follows:

The Work to which this Certificate applies has been inspected by authorized representatives identified below and that Work is hereby declared to be substantially complete in accordance with the Contract Documents on:

A tentative list of items to be completed or corrected is attached hereto. This list may not be all-inclusive, and the failure to include an item in it does not alter the responsibility of Contractor to complete all the Work in accordance with the Contract Documents. The items in the tentative list shall be completed or corrected by the Contractor.

SIGNED:

CONTRACTOR: ____________________________________________________________

By: __________________________________________ Date:______________________________________

FLAGLER COUNTY CONSTRUCTION ENGINEERING & INSPECTION

REPRESENTATIVE:

FLAGLER COUNTY PROJECT MANAGER

OTHER____________________________________________________________________

(2 of 2)

TENTATIVE LIST OF ITEMS TO BE COMPLETED OR CORRECTED

(PUNCH LIST)

Date:________________

COUNTY PROJECT NO.: _____________________

CONTRACTOR: ______________________________________________________

This list may not be all-inclusive, and the failure to include an item does not alter the responsibility of the Contractor to complete all the Work in accordance with the Contract Documents.

ITEM NO. DESCRIPTION

CERTIFICATE OF FINAL COMPLETION

CONTRACT DATE:______________

COUNTY PROJECT NO.: ___________________

This Certificate of Final Completion applies to:

_____ All work under Contract _____ Portion of work described as follows:

The Work to which this Certificate applies has been inspected by authorized representatives identified below and that Work is hereby declared to be complete in accordance with the Contract Documents on:

The tentative list (punch list) of items to be completed or corrected provided with the Certificate of Substantial Completion has been addressed. Failure to have included an item in the does not alter the responsibility of Contractor to complete all the Work in accordance with the Contract Documents.

The date of Final Completion is the date upon which all guarantees and warranties begin.

SIGNED:

CONTRACTOR: ____________________________________________________________

FLAGLER COUNTY CONSTRUCTION ENGINEERING & INSPECTION

REPRESENTATIVE:

FLAGLER COUNTY PROJECT MANAGER

FLAGLER COUNTY ENGINEER

List the subcontractors which have not been paid the proportionate share of payments received by the contractor and the date listed as exception.

To be signed by an officer or director of the Contractor with the authority to bind the Contractor and notarized.

To avoid delay in payment, certification must be submitted to the Project Engineer no later than the Friday before the monthly estimate cutoff date (generally the 3rd Sunday of the month).

County of Sworn to and subscribed before me this

DATE

CONTRACT NO.FIN PROJ. I.D.

, prime contractor for the above referenced contract, hereby certifies that all subcontractors, except for those noted below, having interest in this contract have received their pro rata share of all previous periodic payments made to date by the Department for all work, materials and equipment furnished under the contract. The term "subcontractor", as used herein, shall also include persons or firms furnishing materials, services or equipment incorporated into the work or stockpiled in the vicinity of the project for which partial payment has been made by the Department and work done under equipment-rental agreements.

EXCEPTION:

The following subcontractors have not been paid and a copy of the notification sent to each, explaining the good cause why payment has not been made, is attached to this form:

Subcontractor name

Street Address

City State Zip

Subcontractor name

Street Address

City State Zip

By

Title

State of Florida day of , , by (Print name of person signing Certification)

Notary Public

Personally Known OR Produced Identification Type of Identification Produced

Instructions:

Attach copy of the notification good cause sent to each applicable subcontractor.

2.

3. A separate certification is required for each contract.

4.

5.

TO RELEASE MONTHLY PAYMENT FOR

Commission Expires

1.

Contractor

A false statement or omission made in connection with this certification is sufficient cause for suspension, revocation, or denial of qualification to bid, and a determination of non-responsibility, and may subject the person and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable Federal and State Law.

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

CONSTRUCTION

700-010-38

1/17CERTIFICATION

DISBURSEMENT OF PREVIOUS PERIODIC PAYMENT TO SUBCONTRACTORS

(As required by Florida Transportation Code, Section 337.11, Subsection (11), F.S.)

, not required when digital

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

CONSTRUCTION COMPLIANCE WITH

SPECIFICATIONS AND PLANS

700-020-02

CONSTRUCTION

12/16

FIN PROJECT I.D.(s) DATE:

CONTRACT NO:

Monthly:

Final:

, Prime Contractor for the above referenced contract, hereby verifies based on personal knowledge or reasonable investigation and good faith belief, all Quality Control functions and Quality Control sampling and testing results are in substantial compliance with the contract specification requirements and the approved Quality Control Plan for this project. This includes the input of test results into the Department’s MAC database within 24 hours of results being received. This represents work done between and . Exceptions to these requirements are listed below.

1.) Item No.:

Exception:

2.) Item No.:

Exception:

3.) Item No.:

Exception:

4.) Item No.:

Exception:

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

CONSTRUCTION COMPLIANCE WITH

SPECIFICATIONS AND PLANS

700-020-02

CONSTRUCTION

12/16

5.) Item No.:

Exception:

6.) Item No.:

Exception:

A false statement or omission made in connection with this certification is sufficient cause for suspension, revocation, or denial of qualification to bid, and a determination of non-responsibility, and may subject the person and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable Federal and State Law.

State of Florida County of

Sworn to and subscribed before me this day of , , by (Print name of person signing Certification)

Notary Public (Not Required when Digital)

Commission Expires

Personally Known or Produced Identification

Type of Identification Produced

Quality Control Manager

State of Florida County of

Sworn to and subscribed before me this day of , , by (Print name of person signing Certification)

Notary Public (Not Required when Digital)

Commission Expires

Personally Known or Produced Identification

Type of Identification Produced

Contractor

Signed By

Title

Company

Signed By dleap Text Box

Instructions for Construction Compliance with Specifications and Plans (Form # 700-020-02)

Financial Project Number(s): List all financial project numbers on the contract.

Date: Show the date the certification is completed.

Contract No.: Show the contract number the certification represents.

Monthly/Final: Indicate which type of estimate this certification represents, monthly or final.

Prime Contractor: In this field, show the Prime Contractor’s full company name.

Date Began: Show the beginning date the certification represents. For a monthly or progress estimate, show the beginning date for the estimate period. For a final certification, show the date the contract work began.

Date Ended: Show the ending date for the estimate period. For final certification, show the final acceptance date.

Item No.: Show the pay item number the exception is associated with.

Exceptions:

For the monthly certification, list the following:

1. QC samples that did not compare with VT samples and had VT results upheld by RT samples.

2. Any samples that had Engineering Analysis Report or Delineation Test(s) performed.

3. Any failed QC samples.

4. Any QC samples that do not have results entered into MAC.

5. Any QC samples that were performed by unqualified technicians or laboratories.

6. Any materials placed without an approved QC Plan or when the QC Plan is suspended.

7. Any materials provided from an unapproved producer or supplier.

8. Results of any failing Chloride content limits as defined in Specification 346-4.2.

The following would not be listed as an exception on the subject form:

1. QC samples that have been tested but not verified.

2. QC samples that have been tested and had verification test results that did not compare.

For the final certification, all exceptions to QC sampling and testing must be shown on the certification.

Notary Information: The Notary of the Public completes this section. This certification must be notarized.

Quality Control Manager: Name of the Quality Control Manager that will sign the certification.

Company: Enter the name of the company the Quality Control Manager is employed by.

Contractor: Name of an officer or director of the Contractor with an authority to bind the Contractor.

Signed By: To be signed by the person's name under the "Contractor" section.

Title: Enter the title of the person signing the certification.

It is not the Department’s intent for Contractors to list as exceptions samples and results for which they are not responsible, such as verification and independent verification samples and test results. Additionally, the Department will accept exports of the Sample Search Results in MAC, as an attachment, to assist in documenting the status of samples.

Signed By: To be signed by the "Quality Control Manager".

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Stormwater Pollution Prevention Plan Inspection Report Form Inspections must occur at least once a week and within 24 hours of the end of a storm event that is 0.50 inches or greater.

Project Name:___________________________________________________________ FDEP NPDES Stormwater Identification Number: FLR10______

Location Rain data

Type of control (see below)

Date installed / modified

Current Condition (see below)

Corrective Action / Other Remarks

Condition Code:

G = Good M = Marginal, needs maintenance or replacement soon P = Poor, needs immediate maintenance or replacement C = Needs to be cleaned O = Other

Control Type Codes

1. Silt Fence 10. Storm drain inlet protection 19. Reinforced soil retaining system 28. Tree protection

2. Earth dikes 11. Vegetative buffer strip 20. Gabion 29. Detention pond

3. Structural diversion 12. Vegetative preservation area 21. Sediment Basin 30. Retention pond

4. Swale 13. Retention Pond 22. Temporary seed / sod 31. Waste disposal / housekeeping

5. Sediment Trap 14. Construction entrance stabilization 23. Permanent seed / sod 32. Dam

6. Check dam 15. Perimeter ditch 24. Mulch 33. Sand Bag

7. Subsurface drain 16. Curb and gutter 25. Hay Bales 34. Other

8. Pipe slope drain 17. Paved road surface 26. Geotextile

9. Level spreaders 18. Rock outlet protection 27. Rip-rap Inspector Information:

Name Qualification Date The above signature also shall certify that this facility is in compliance with the Stormwater Pollution Prevention Plan and the State of Florida Generic Permit for Stormwater Discharge from Large and Small Construction Activities if there are not any incidents of non-compliance identified above.

"I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations."

Name (Responsible Authority) Date