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APPLICATION AND CERTIFICATION FOR PAYMENT TO OWNEI Indian River County; Department of Utility PROJECT 2015029 Services FROM CONTRACTOR: VIA ARCHITECT - General Underground 7650 NW 50th St Chiefland , FI 32626 CONTRACT FOR: CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Document 0703, is attached. 1. ORIGINAL CONTRACT SUM 2. Net change by Change Orders 3. CONTRACT SUM TO DATE (Line 1 t 2) 4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) 5. RETAINAGE: a. 0 % of Completed Work (Column D + E on G703) b. % of Stored Material (Column F on G703) Total Retainage (Lines 5a + 5b or Total in Column I of G703) 6. TOTAL EARNED LESS RETAINAGE (Line 4 Less Line 5 Total) 7 LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) 8. CURRENT PAYMENT DUE 9. BALANCE TO FINISH, INCLUDING RETAINAGE (Line 3 less Line 6) CHANGE ORDER SUMMARY Total changes approved in previous months by Owner Total approved this Month TOTALS NET CHANGES by Change Order $ 123,779.36 $ 0.00 $ 123,779.36 $ 92,215.46 $ $0.00 $ Included in above $ 0.00 $ 92,215.46 $ 83,839.46 4 8,376.001 $ 31,563.90 AIA DOCUMENT G702 PAGE 1 OF t APPLICATION NO: Final Distribution to: X OWNER X ARCHITECT PERIOD TO: 2/3/2016 X CONTRACTOR PROJECT NOS. UCP#4109 CONTRACT DATE: The undersigned Connector certifies that to the best of the Contractor's knowledge, information and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. CONTRACTOR: General Underground 1 t By Date: 2/3/2016 Stale of: %lG County of: (.0 V t Subscribed an sw '' efore me this lvD day of ret-�y'-q XO (, �o Notary Public: tiTl�� - &0kl\ My Commission ezpves: � ap �� ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on-site observations and the data comprising the application, the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. AMOUNT CERTIFIED $ ADDII70NSIDEDUCTIONS (Attarh explanation if amount certified differs from the amount applied. Initial all figures on this Application and onlhe Continuation Sheet that are changed to conform with the amount certified.) $0.00 $0.00 ARCHITECT $0.00 $0.00 By Date: $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without $0.00 oreiudice to any fights of the Owner or Contractor under this Contract. AIA DOCUMENT 0702, APPUCATION AND CERTIFICATION FOR PAYMENT 1882 EDITION AIA • 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1795 NEW YORK AVE, N.W., WASHINGTON, DC 20000b292 Users may obtain validation of this document by requesting a completed AIA Document D401 - Certification of Document's Authenticity from the Licensee. MAGGIE MING * MY COMMISSION # FF 218581 EXPIRES: April 8, 2019 uMr.mdeBondedThru Budget Notary Seryket