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SECTION 00622 - Contractor's Application for Payment <br />66th Avenue Roadway Improvements (SR 60 to North of 49th Street) <br />Application for Payment No. 29. <br />For Work Accomplished through the period of May 1, 2015 through June 30, 2015. <br />To: INDIAN RIVER COUNTY <br />From: DICKERSON FLORIDA INC (CONTRACTOR) <br />Bid : 2013008 <br />Project: 0545 & 0370 <br />1) Attach detailed schedule and copies of all paid invoices. <br />f, s, <br />:rr <br />1:11 \.% S ON <br />1. Original Contract Price: <br />2. Net 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 />95% of completed Work: $20,239,868.41 <br />0% of retainage: $ _ .00 <br />Total Retainage: $ .00 <br />6. Total completed and stored to date less retainage (4 minus 5): $19,227,874.99 <br />7. Less previous Application for Payments: $19,227,874.99 <br />$20,773,389.09 <br />$ 485,709.63 <br />$21,259,098.72 <br />$20,239,868.41 <br />8. DUE THIS APPLICATION (6 MINUS 7): <br />$ 1,011,993.42 <br />** Attach detailed schedule of materials and copies of all invoices with lien releases <br />CONTRACTOR'S CERTIFICATION: <br />UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor <br />and materials listed on this request for payment have been used in the construction of this Work; (2) <br />payment received from the last pay request has been used to make payments to all subcontractors, <br />laborers, materialmen and suppliers except as listed on Attachment A, below; (3) title of all Work, <br />materials and equipment incorporated in said Work or otherwise listed in or covered by this <br />Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security <br />interests and encumbrances (except such as are covered by a Bond acceptable to OWNER <br />indemnifying OWNER against any such Lien, security interest or encumbrance); (4) all Work <br />covered by this Application for Payment is in accordance with the Contract Documents and not <br />defective; and (5) If this Periodic Estimate is for a Final Payment to project or improvement, I further <br />certify that all persons doing work upon or furnishing materials or supplies for this project or <br />improvement under this foregoing contract have been paid in full, and that all taxes imposed by <br />Chapter 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and <br />discharged, and that I have no claims against the OWNER. <br />Attached to or submitted with this form are: <br />1. Signed release of lien forms (partial or final as applicable) from all subcontractors, laborers, <br />materialmen and suppliers except as listed on Attachment A, together with an explanation as <br />to why any release of lien form is not included; <br />Retainage Pay Request #29 <br />00622 - 1 <br />Z\My Documents\Excenspecial est tonns\3949 - 66th\Retainage Pay Request #29.doc Rev. 05/01 <br />112 <br />