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APPLICATION FOR PAYMENT NO <br />To: Indian River Count <br />From: (OWNER) <br />Contract: (CONTRACTOR) <br />Project: Brine Line Conversion To A Potable Water Main — 77 Street <br />OWNER's Contract No. <br />For Work accomplished through the date of: ENGINEER's Project No. 08-091 <br />2. <br />K� <br />4 <br />Original Contract Price: <br />Net change by Change Orders and Written Amendments (+ or <br />Current Contract Price (1 plus 2): <br />Total completed and stored to date <br />5. Retainage (per Agreement): <br />Of completed Work: $ <br />of stored material: $ <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 />Accompanying Documentation: <br />CONTRACTOR'S Certification: <br />$ <br />$ <br />The undersigned CONTRACTOR certifies that (1) title to all Work, materials and equipment incorporated in <br />said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of <br />payment free and clear of all Liens, security interests and encumbrances; (2) all Work covered by this <br />Application for Payment is in accordance with the Contract Documents and not defective; and (3) the labor <br />and materials listed on this Application for Payment have been used in the construction of this Work <br />and payment received from the last progress payment has been used to make payments to all <br />subcontractors, laborers, material, men and suppliers except as listed below: " <br />Dated <br />State of By: <br />CONTRACTOR <br />County of <br />Subscribed and sworn to before me this <br />day of <br />Notary Public <br />My Commission expires: <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated <br />ENGINEER <br />EJCDC No. C -700-E (2002 Edition) U <br />Prepared by the Engineers Joint Contract Documents Committee and endorsed by The Associated General Contractors of America and the Construction <br />Specification Institute. <br />00800-29 <br />