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APPLICATION AND CERTIFICATION FOR PAYMENT AIrt DOCb. 11I`:N" 7' 6t�� f12 PAGE ONE OF 2 PAGES TO OWNER: PROJECT: APPLICATION NO: FiNAL Distribution to: Indian River County IRC 13020120217 SCRO = OWNER Vera Beach, F'L .12960 = ARCdiTEC3. PERIOD TO: 9131 /2012 = CONrI'RAC 0I%(')It i FR« 41CONTRAC0W VIA ARC'HI 'CEC"f: I Technical Electric Systems tile . F—'1 87 S Highway 17,992, Unit B PROJECT NOS : IRC BID2012027 SCRO L _! DeBary, FL 32713 CUNTRAC'f FOR: CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT The wtdersigned Ctxllractnrcertifies that t0 the best of' (he Contractor's knowledge. Application is made thr payment. as shown below. in connection with the Contract, intonnation and belief the Work covered by this Application for Payment has been Continuation ShCCL AIA Document 6703 . is attached. completed in accordance with the Contracl Documents, that all amounts have been paid be the Contractor for Work for which previous Certificates for ['ayntem were issued and j payments received from the OwT1er. and that current pay+nent shown herein i. now due. 1 . ORIGINAL CONTRACT SUM S 39.288.70 2. Net change by Change Orders S 27,202.29 CONTRACTOR: 3. CONTRACT SUM TO DATE (Line I z 2) $ 667490.99 4. TOTAL COMPLETED & STORED TO S 667490.99 DATE (Column G on G703) By: Date: 5. RETAINAGE: a . 5 % of Completed Work $ 3,325 State of FLCRtDik County of YOC. "��o KIMMLY MALLORY (Column D + Eon 6703 ) Subscribe d and sw rn ro Before the this I5 f�' v of aoVt Na ry Pt�1ie - State a4 FCtnld b 4 uo of Stared Material Notary Public Myemne Expires Sep 8, 201 (Column F ort G703) ` t. a+ i Total Retainage ( kine. 5a + Sb or My Commtssron a fifes: as o t.�/,�ot ' Cotttalbttiott 0 EE 84981 OF Bondi 1Wo* NOW0 " As Total in Column I ofG7031 S 33241 55 ARCHITECT'S ER FI E h ! 71IEARNED LESS Rl [ Afv1Gt, 63, 166.44 In accordance with the Contract Documents. based on on-site oh,crvations and the data (Line 4 Less Line 5 `i otal) comprising the application, the Architect oertiftes to the Owner that to the best of the 7. L,l44SS PR.EVIOI.IS CERTIFICATES POR. Architect's knowledge, information and belief the Work has progressed as indicated, 1'AY44ENT' {Line 6 fromprior Certificate} S 57,614.88 the quality of Ute Work is in accordance evith the Contract Documents. and the Contractor 8 , C't IRRENT PAYMENT D1. 13 8,876. 1 1 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH. INCLUDINIG RETAINAGE 0.00 (. Line 3 less tine b) AMO[.INTCIR`hletl:D : . . . . . . . . . . S -- " CHANGE ORDERSUMMARY ADDITIONS D _ i;4ttac }t ect�lanaiir�+t +mount ertifie[l dijferi.liw+++ Jhe alnnb+if tr/mh +t. /!tifird +7f1 J+ � n Von this Total changes approved Application arkf ortthe C ontinuatiun+ 9wet that are chatiged to cott i)r in with the tarn:711,11 certified ; in previous months by Owner 521 , 358.34 4ttE=ft}; ,Vv� E Total approved this Month 55;843.75 !34 � / v Date: iLh� '1A9 . fC)`fAt ,S 527,202.29 : $0.00 This Cert > •t �t' :I2 .D is pa;able only to the t onaactoralatned herein. Issuance. jmtvment .cl I mens are wilhuut NL t' CH.ANGI S by Change Order 527,202.29 prejudicEk eft t IV�t 1AMMI r. 04 � act. Au. DOCUMENT 0702 APPLICATION AND CERTitiCATION FOR PAYMENT 1992 EDITION - AIA 01992 THE AMERPCANINSTITUTE OF ARCHITECTS. 1735 NEW YORK .AVE. N W,WASHINGTON, DC 2000r CZ92 Users may obtain validation of this document by requesting a completed AIA Document D401 - Certification of Document's Authenticity from the Licensee.