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original of any change order approved by the Dodgers increasing the costs of the <br /> Improvements in an amount in excess of the original price therefor; <br /> (� Bills of sale for any component of the Improvements for which a bill of sale may be <br /> delivered; and/or <br /> (� A true copy of the Payee's statement or invoice. <br /> 4. Please disburse the following amount to the following Payee (if more than one Payee, <br /> please attach additional pages hereto setting forth the following information): <br /> Payee: <br /> Amount: <br /> Address: <br /> Invoice No.: <br /> 5. To induce the County to approve this Requisition and authorize the County Clerk to <br /> disburse funds held in the Construction Fund, the undersigned certifies that there are no <br /> outstanding construction liens against the Facility. <br /> 6. The following constitutes an itemized list of attachments to this certificate, if applicable: <br /> (a) Contractor's Application for Payment (AIA Forms G702 and 0703). <br /> (b) Architect's Certificate (AIA Forms G702 and G703). <br /> EXECUTED this day of , 20 <br /> LOS ANGELES DODGERS, INC. <br /> By: <br /> (Authorized Signature) <br /> Approved for payment: <br /> INDIAN RIVER COUNTY, FLORIDA <br /> By: <br /> County Administrator(or designee) <br /> D-2 <br />