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SECTION 00622 - Contractor's Application for Payment <br /> Indian River Boulevard Resurfacing <br /> (41 St Street to 53rd Street) <br /> Application for Payment No . <br /> For Work Accomplished through the period of through <br /> To : Indian River County (OWNER) <br /> From : (CONTRACTOR) <br /> Bid : 2013007 <br /> Project : 1131 <br /> 1 ) Attach detailed schedule and copies of all paid invoices. <br /> 1 . Original Contract Price : $ <br /> 2 . Net change by Change Orders and Written Amendments (+ or -) : $ <br /> 3 . Current Contract Price ( 1 plus 2) : <br /> 4 . Total completed and stored to date : $ <br /> 5 . Retainage ( per Agreement) : <br /> % of completed Work: $ <br /> of retainage : $ <br /> Total Retainage : $ <br /> 6 . Total completed and stored to date less retainage (4 minus 5) : $ <br /> 7 . Less previous Application for Payments . $ <br /> 8 . DUE THIS APPLICATION 6 MINUS 7) : $ <br /> CONTRACTOR'S CERTIFICATION : <br /> UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that ( 1 ) the labor <br /> and materials listed on this request for payment have been used in the construction of this Work; (2) <br /> payment received from the last pay request has been used to make payments to all subcontractors , <br /> laborers , materialmen and suppliers except as listed on Attachment A, below; (3) title of all Work, <br /> materials and equipment incorporated in said Work or otherwise listed in or covered by this <br /> Application for Payment will pass to OWNER at time of payment free and clear of all Liens , security <br /> interests and encumbrances (except such as are covered by a Bond acceptable to OWNER <br /> indemnifying OWNER against any such Lien , security interest or encumbrance) ; (4) all Work <br /> covered by this Application for Payment is in accordance with the Contract Documents and not <br /> defective ; and (5) If this Periodic Estimate is for a Final Payment to project or improvement , I further <br /> certify that all persons doing work upon or furnishing materials or supplies for this project or <br /> improvement under this foregoing contract have been paid in full , and that all taxes imposed by <br /> Chapter 212 Florida Statutes , (Sales and Use Tax Act , as Amended) have been paid and <br /> discharged , and that I have no claims against the OWNER . <br /> Attached to or submitted with this form are . <br /> 1 . Signed release of lien forms (partial or final as applicable) from all subcontractors , laborers , <br /> materialmen and suppliers except as listed on Attachment A , together with an explanation as <br /> to why any release of lien form is not included ; <br /> 00622 = Contractor's Application for Payment = 03- 10 rev, doc <br /> 00622 - 1 <br /> FAPublic Works%ENGINEERING DIVISION PROJECTSN 131411 Blvd Resurfacing 41st St to 53rd StSEE PROJ 0927Wdmim\Contract Documents\00622 - Contractor's Application <br /> for <br /> Payment - 03-10 rev.doc Rev. 05/01 <br />