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SECTION 00622 = Contractor's Application for Payment <br /> 66th Avenue Roadway Improvements ( S . R. 60 to North of 49th Street) <br /> Application for Payment No . <br /> For Work Accomplished throuqh the period of through <br /> To : Indian River County (OWNER) <br /> From : (CONTRACTOR) <br /> Bid No . : 2013008 <br /> Project No . : 0545 & 0370 <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 /> 14 . Total completed and stored to date : $ <br /> 50 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 /> 00622 - Contractor's Application for Payment = 03-10 rev.doc <br /> 00622 - 1 <br /> RkPublic WorkslENGINEERING DIVISION PROJECTS10545,66Th Ave SR60 to 57th St (Arcadis)1AdmimlBid Documents\00622 - Contractor's Application for Payment - 03=10 <br /> rev.doc <br /> Rev. 05/01 <br /> F <br />