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SECTION 00622 - Contractor's Application for Payment (47th Street Roadway Improvements east of US1 to Terminus) For Work Accomplished through the period of Applicatithrfor oughayment No. To: Indian River County (OWNER) From: (CONTRACTOR) Bid : 2010033 Project: 0946 1) Attach detailed schedule and copies of all paid invoices. 1. Original Contract Price: 2. Net change by Change Orders and Written Amendments (+ or -): 3. Current Contract Price (1 plus 2): 4. Total completed and stored to date: $ 5. Retainage (per Agreement): of completed Work: $ % of retainage: $ Total Retainage: $ 6. Total completed and stored to date less retainage (4 minus 5): $ 7. Less previous Application for Payments: $ 8. DUE THIS APPLICATION (6 MINUS 7): $ ** Attach detailed schedule of materials and copies of all invoices with lien releases CONTRACTOR'S CERTIFICATION: UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor and materials listed on this request for payment have been used in the construction of this Work; (2) payment received from the last pay request has been used to make payments to all subcontractors, laborers, materialmen and suppliers except as listed on Attachment A, below; (3) title of all Work, materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien, security interest or encumbrance); (4) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective; and (5) If this Periodic Estimate is for a Final Payment to project or improvement, I further certify that all persons doing work upon or furnishing materials or supplies for this project or improvement under this foregoing contract have been paid in full, and that all taxes imposed by Chapter 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and discharged, and that I have no claims against the OWNER. Attached to or submitted with this form are: 1. Signed release of lien forms (partial or final as applicable) from all subcontractors, laborers, 00622 - Contractor's Application for Payment - 03-10 rev.doc 00622 - 1 F:\Public Works \ENGINEERING DIVISION PROJECTS\0946-4711H Street (US1 to Terminus Point)Wdmim\bid documents\0946 Contract Documents100622 - Contractor's Application for Payment - 03-10 rev.doc Rev. 05/01