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1 <br /> CONTRACTOR'S CERTIFICATION : <br /> UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that ( 1 ) the labor and <br /> materials listed on this request for payment have been used in the construction of this Work and <br /> payment received from the last request for payment has been used to make payments to all <br /> tsubcontractors , laborers , materialmen and suppliers except as listed below; (2 ) title of all Work , <br /> materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for <br /> Payment will pass to OWNER at time of payment free and clear of all Liens , security interests <br /> and <br /> encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER <br /> against any such Lien , security interest or encumbrance ) ; (3 ) all Work covered by this Application <br /> for <br /> Payment is in accordance with the Contract Documents and not defective and (4) If this Periodic Estimate <br /> is for a Final payment to project or improvement, I further certify that all persons doing work <br /> upon or <br /> furnishing materials or supplies for this project or improvement under this foregoing contract have been <br /> paid in full , and that all taxes imposed by Chapter 212 Florida Statutes , (Sales and Use <br /> Tax Act , as <br /> Amended ) have been paid and discharged , and that I have no claims against the OWNER . <br /> ' Dated <br /> ( CONTRACTOR) <br /> IBy: <br /> State of <br /> County of <br /> Subscribed and sworn to before me this <br /> day of <br /> Notary Public <br /> My Commission expires : <br /> NOTICE OF NON-PAYMENT. If one or more "Notice of Non-Payment " or "Notice to Owner" is <br /> received by the OWNER, no further payments will be approved until non-payment(s) have been <br /> satisfied and a "Lien Waiver" for each "Notice " has been submitted to the OWNER. Upon request, <br /> CONTRACTOR shall furnish acceptable evidence that all such claims have been satisfied. The <br /> jCONTRACTOR may, with consent of Surety and indemnification of the OWNER against any <br /> claims, receive payment for work for which there is an outstanding "Notice of Non -Payment" or <br /> "Notice to Owner. " <br /> [The remainder of this page was left blank intentionally] <br /> 1 <br /> 0378-00622 - Contractor's Application for Payment <br /> 00622 - 2 <br /> FAEngineering\Capital Projects\0378-26th Street Bridge\0378-26th Street Bridge CONTRACT DOC\0378-00622 - Contractor's Application for Payment.doc Rev. 05/01 <br />