ࡱ> g|$bjbjpp4, j j-DD!!!!!!!!8-"$Q"4!z"""""###zzzzzzz1~z9!#####z!!""4Iza%a%a%#F!"!"za%#za%a%6g u",#qy_z0zjr>$uu!vT##a%#####zz%^###z#############Dc : ZaBcznik nr 5 do SWZ IM.271.17.2024 Podmioty, w imieniu ktrych skBadane jest o[wiadczenie: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEIDG)& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & (peBna nazwa/firma, adres, w zale|no[ci od podmiotu: NIP/PESEL, KRS/CEIDG)reprezentowane przez:& & & & & & & & & & & & & & & & & & & ..& ..& & & &  (imi, nazwisko, stanowisko/podstawa do reprezentacji) O[wiadczenie o realizacji robt przez poszczeglnych wykonawcw wsplnie ubiegajcych si o zamwienie na podstawie art. 117 ust. 4 ustawy z dnia 11 wrze[nia 2019 r. Prawo zamwieD publicznych O[wiadczam, |e nastpujce roboty: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & FHbdrtj l  T  ͼͪwfTfff@fff&h#hv5>*CJOJQJ^JaJ#h#hvCJOJQJ\^JaJ h#hvCJOJQJ^JaJ#h#h5CJOJQJ^JaJh"]5CJOJQJ^JaJ#h#hv5CJOJQJ^JaJ#h#h}5CJOJQJ^JaJ h#h-vCJOJQJ^JaJ h#h}CJOJQJ^JaJ h#h; CJOJQJ^JaJ h#h_-CJOJQJ^JaJHtl  $ p#$1$Ifa$gdFkd$$If7bb tb47a7p yt $Ifgdgdvdgdv $da$gd}       Vdzܟ܍vvtvv`v'h#B*CJOJPJQJ^JaJphU-h#hvB*CJOJPJQJ^JaJph#h#hv5CJOJQJ^JaJ'h#hv6CJOJPJQJ^JaJ&h#hv5CJOJQJ\^JaJ)h#hv5>*CJOJQJ\^JaJ h#hvCJOJQJ^JaJ#h#hv6CJOJQJ^JaJ   jX$ p#$1$Ifa$gdFkd$$If7bb tb47a7p yt $IfgdFkdc$$If7bb tb47a7p yt  ]K$ p#$1$Ifa$gdFkd$$If7bb tb47a7p yt$ p#$1$Ifa$gdFkd)$$If7bb tb47a7p yt  aYTYL$a$gd&igdv$a$gdvFkdR$$If7bb tb47a7p yt$ p#$1$Ifa$gdFkd$$If7bb tb47a7p ytV$&n H!!LL7xx$d%d&d'd(dNOPQR^gdLU:$xx$d%d&d'd(dNOPQR^a$gdvB$ & F&xx$d%d&d'd(d7$8$H$NOPQR^a$gdv& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & Wykona wykonawca: & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & & & & & .. O[wiadczam, |e nastpujce roboty: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & wykona wykonawca: & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & & & & & & & ..& & .. O[wiadczam, |e nastpujce roboty: & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & .& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & wykona wykonawca: & & & & & & & & & & & & & & & & & & & & ..& & & & & & & & & & & & & & ..& & & & & & & & & & .. 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