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ITI <br /> 4 111 1171 <br /> IL e <br /> 1'14 <br /> 41 10 <br /> S YA _ +- ` r fr , llr <br /> aFP . <br /> SECTION 00622 = Contractor' s Application for Payment <br /> { 66t" Avenue Roadway Improvements - Phase 2 ( 4t" Street to 16t" Street ) <br /> ,k <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 : 2012032 <br /> Project : 9810- B <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 <br /> 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 - 1 00622 - Contractor's Application for Payment - 03- 10 rev . doc <br /> F :\Public Works\ENGINEERING DIVISION PROJECTS\98106-66th Ave Ph 2 4th St to 16th St\Admim\bid documents\00622 - Contractor's Application for Payment <br /> - 03- 10 rev. doc <br /> Rev. 05/01 <br />