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Dated <br /> ( CONTRACTOR ) <br /> By: <br /> State of <br /> County of <br /> Subscribed and sworn to before me this <br /> day of <br /> Notary Public <br /> My Commission expires : <br /> CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLE ) : <br /> certify that I have checked and verify the above and foregoing Periodic Estimate for Partial Payment; that to the best of my knowledge <br /> and belief it is a true and correct statement of the work performed and/or material supplied by the Contractor . <br /> Dated <br /> (ARCHITECT / ENGINEER ) SIGNATURE <br /> CERTIFICATION OF ENGINEER / INSPECTOR : <br /> I have checked the estimate against the Contractor' s Schedule of Amounts for Contract Payments and the notes and reports <br /> of my <br /> inspections of the project . It is my opinion that this statement of work performed and /or materials supplied is accurate , that the <br /> Contractor <br /> is observing the requirements of the Contract , and that the Contractor should be paid the amount requested above . <br /> Dated <br /> (ARCHITECT / ENGINEER ) SIGNATURE <br /> Accompanying Documentation : <br /> 00800 -28 <br />