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Page 2 of 5 <br />2. Updated Construction Schedule per Specification Section 01310, a d <br />Dated / By: <br />(CONTRACTOR u signed by <br />an Officer of the Corporation) <br />Print Name and Title <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <br />Before me, a Notary Public, duly commissioned, qualified, and acting, personally appeared <br />Vt , 2 ' who being by me first duly sworn upon oath, says that he/she is the <br />0 WU,IAiw�4 of the CONTRACTOR mentioned above and that he/she has been duly <br />authorized to act on behalf of it, and that he/she executed the above Contractor's Application for <br />Payment and Contractor's Certification statement on behalf of said CONTRACTOR; and that all of <br />the statements contained herein are true, correct, and complete. Subscribed and sworn to before <br />me this day of a ✓ , 20..x. <br />11�Jmobrrl to me or has produced <br />as I en Ica Ion. <br />NOTARY PUBLIC: &AdjW-1 -d( <br />(SEAL) Printed name:(lam �j n �� 11 f�C v'6 ��t4 <br />_;;►";�. DEBORAH A CROCKETT Commission No. o <br />'e MY COMMISSION # EE209641 Commission Expiration: dit &,e- L %, <br />EXPIRES June 19, 2016 <br />(40 398-0157 FlorWeNolmySeryme.com <br />�'� f1y�iFtk�klMr*�k�kh***lk�Flkt►lttt*#iF'k+F�k***�kiF#�k*�k*+IF�Ir#'�tR11r1k1Hk***+Inlbir+kilnR+i*IklF1FlF <br />[The remainder of this page was left blank intentionally] <br />00622 - Contractors Application for Payment - 03-10 rev <br />00622 - 2 29 <br />C:W"mr�a <br />o*mwoatau,omrmia wmwuxbwb1Twpmry Warnet FilesWwderd.OWookl5ZV45NO2100622 - ConVacWfs Application for payment - 03-10 rev.doc Rev. 05!01 <br />