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Page 4 of 6 <br /> CERTIFICATION OF ENGINEER : <br /> I certify that I have reviewed the above and foregoing Periodic Estimate for Partial <br /> Payment ; that to the best of my knowledge and belief it appears to be a reasonably <br /> accurate statement of the work performed and/or material supplied by the Contractor. I am <br /> not certifying as to whether or not the Contractor has paid all subcontractors , laborers , <br /> materialmen and suppliers because I am not in a position to accurately determine that <br /> issue . <br /> Dated <br /> SIGNATURE <br /> CERTIFICATION OF INSPECTOR : <br /> I have checked the estimate against the Contractor's Schedule of Amounts for Contract <br /> Payments and the notes and reports of my inspections of the project. To the best of my <br /> knowledge , this statement of work performed and/or materials supplied appears to be <br /> reasonably accurate , that the Contractor appears to be observing the requirements of the <br /> Contract with respect to construction , and that the Contractor should be paid the amount <br /> requested above , unless otherwise noted by me . I am not certifying as to whether or not <br /> the Contractor has paid all subcontractors , laborers , materialmen and suppliers because I <br /> am not in a position to accurately determine that issue . <br /> Dated <br /> SIGNATURE <br /> [The Remainder of This Page Was Left Blank Intentionally] <br /> 00622 - Contractor's Application for Payment - 03- 10 rev. doc <br /> 00622 - 4 <br /> F:%Public WorksTENGINEERING DIVISION PROJECTS111314R Blvd Resurfacing 41st St to 53rd St-SEE PROD 09271Admim\Contract Documents100622 - Contractor's Application <br /> for <br /> Payment - 03-10 rev.doc Rev. 05/01 <br />