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APPLICATION FOR PAYMENT' N0, <br />to Indian River County— __ (OWNER) <br />From: <br />Contract (CONTRACTOR) <br />Project: J'Water Main Extension Along Lateral G Canal --AND-- 1l3" Reuse Water -_577th ST to 53rd ST <br />OWNER's Contract No. UCP # 21330 ENGINEER's Project No ._U627 <br />For Work accomplished through the date of. <br />1 Original Contract Price: <br />2 Not change by Change Orders and Written Amendments (+ or ) <br />3. Current Contract Price (1 plus 2). <br />4 Total completed and stored to date <br />5 Retainage (per Agreement). <br />70 of completed Work $ <br />of stored material: $ <br />Total Retainage: <br />5 Total completed and stored to date less retainage (4 minus 5) <br />7 Less previous Application for Payments: <br />8. DUE THIS APPLICATION (G MINUS 7): <br />Accompanying Documentation <br />CONTRACTOR'S Certification: <br />The undersigned CONTRACTOR certifies that (1) title to all Work, materials and equipment incorporated In said <br />Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment <br />free and clear of all Liens, security interests and encumbrances, (2) all Work covered by this Application for <br />Payment is in accordance with the Contract Documents and not defective, and (3) the labor and materials <br />iisted on this Application for Payment have been used in the construction of this Work and payment <br />received from the last progress payment has been used to make payments to all subcontractors, <br />laborers, material, men and suppliers except as listed below. " <br />Dated <br />State of By: _ — -- <br />County - <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 />CONTRACTOR <br />_._ M.ASTELLE_R & MOLER. INC <br />ENGINEER <br />By------------___-. _. -- - _ <br />FXDC No C -700-E (2002 Edition) <br />Re, aged Dy re F ng flee, & to -n1 Co www O(xL reeds co mcuttee and tfrdasPd t•+ Tree AsI,ocwen G: -neral Ccntiactys p' A.neeie•aa and leCass^.rut€-c:n <br />Sca+cat�n Instdote <br />00800.20 <br />U .rJ VISION M0600 aail{•In_rnent3ry CJ)f1J4.ece:5 dile <br />