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SECTION 00622 - Developer Contractor Application for Payment Application for Payment Noy FINAL — 100 % COMPLETE For Work Accom lished flaI it h the eriod of through 9~ 4 :74 200 To : Indian River Goun OWN R From : Tri - Sure Corporation _ (CONTRACTOR OR ENGINEER) Project Name : 16 " 83wage Force riAgii ^ on Ofd Dixie COUNTY WIP NO . : 472 . 169000 02526 00 ENGINEER OF RECORD : ! KI! Pr Mo 1 P inc . Fal Gontract Price: hange by Changes Orders and Written Amendments (+ or _) : 1 , 272 782 . 50 nt Contract Price ( 1 plus 2) : - 48 , 005 . 25 completed and stored to date (*) : 1 , 224 , 777 . 25 nage (per Agreement) : 1 , 224 , 777 . 2510% of completed Work : - 0 - 9% of stored material; 0 . 00 completed and stored to date less retainage (4tmial nus 5) .x - o ' 7 • Less previous Application for Payments: g ( ) 1 , 224 , 777 . 25 8• DUE THIS APPLICATION 6 MINUS 7 : 1 , 078 , 449 . 52 0. 00 � appi/eable, an itemized list of labor and/or materials furnished and installed I s at#4 6 , 3 4 . 7 7 3 C'ONTRACTOR'S CERTIFICATION: The undersigned CONTRACTOR certifies that (1 ) all previous progress payments received from OWNER on account of Work done under the Contract referred to above have been applied an account to discharge CONTRACTOR's legitimate obligations incurred in connection with Work covered by prior Applications for Payment numbered 1 through 2 inclusive ; (2 ) title of all Work, materials and equipment incorporated in said Work or othe Application for Payrwise listed in or covered by this Payment wilt pass to OWNER at time of payment free and clear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien , security interest or encumbrance) ; (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and no defective and (4) If this Periodic Estimate is for a Final payment to project or improvement, I further certify that all persons doing work upon Of furnishing materials or supplies for this project or improvement under this foregoing contract have been Raid in full , and that all taxes imposed b No 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been .d y that i have no claims against the OWNER. P discharged , and Dated =�� , s 13 2003 T i - Sure Corp a in NTRAGT nil By: State of Florida County of po a on Chambers , Vice President IIIIIIII3ubscrtbed and swum to before me — dthis y of u ust 2003 Irl, , NO\U\6\\uuuuuouou HMN\\NpNHNN\\= Notary PublicA� +��" O1j"1,, LII CHAMBERSSHELFER ; a� %tSkl DUB �,, Commission # DD0096710 r =_ Expires 3/3/2006 = 4R AttachmentE? cr3d , d ythrough Assn .2 ---:,� f -, . . , � ryAssn . . �n� ,� \ uuusa \ a: aseuu . wuuuouNN\N .aaToW * .aaTTa4seW d6 : ZT co a0 unr