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Page 2 of 5 <br /> 2 . Updated Construction Schedule per Specification Section 01310 , and <br /> Dated By : <br /> (CONTRACTOR — must be signed by <br /> an Officer of the Corporation) <br /> Print Name and Title <br /> STATE OF FLORIDA <br /> COUNTY OF INDIAN RIVER <br /> Before me , a Notary Public , duly commissioned , qualified , and acting , personally appeared <br /> who being by me first duly sworn upon oath , says that he/she is the <br /> of the CONTRACTOR mentioned above and that he/she has been duly <br /> authorized to act on behalf of it , and that he/she executed the above Contractor's Application for <br /> Payment and Contractor's Certification statement on behalf of said CONTRACTOR ; and that all of <br /> the statements contained herein are true , correct , and complete . Subscribed and sworn to before <br /> me this day of , 201 _ffi <br /> is personally known to me or has produced <br /> as identification . <br /> NOTARY PUBLIC : <br /> (SEAL) Printed name : <br /> Commission No . : <br /> Commission Expiration : <br /> [The remainder of this page was left blank intentionally] <br /> 00622 - Contractor's Application for Payment - 03- 10 rev. doc <br /> 00622 - 2 <br /> F:\Public WorksIENGINEERING DIVISION PROJECTS11102-01d Dixie Hwy Swk 8th St to SR 60-LAP%Admim\bid documentsWaster Contract Documents100622 - Contractors <br /> Application for Payment - 0310 rev.doc Rev. 05/01 <br />