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To: <br />From: <br />APPLICATION FOR PAYMENT N0. 4 - FINAL Retention <br />tndfen River County BOCC <br />Galt Slants Inriustriee, Inc. <br />(OWNER) <br />(CONTRACTOR) <br />Contract BID NO,2013040 <br />Project: Root Repttzcment Pulled el the Hobart RO Flanl, Sault County RO Plonl, and South Rniional Wastewater Treatment Redlines <br />OWNER's Contract No. . 1-10-14 •ENGINEER'S Project No. <br />For Work accomplished through the date of: <br />1. Original Contract Price: • ' • <br />2. • Net change by Change Orders and Written Amendments (+ or -): <br />3. Current ContractPrice (1 plus.2): <br />4. . Total.completed andstored to date <br />5. Retainage (per Agreement):. <br />0 <br />% of completed Work: S <br />% of retainage: <br />S 249.500.00 <br />$ 17,150.00 <br />266,650.00 <br />5 256,650.00 <br />Total Retainage:. $ 0 <br />6.. Total completed and stored to date Tess retainage (4 minus 5): <br />7. Less previous Application for Payments: $ 253.317.50 <br />8. DUE THIS APPLICATION (6 MINUS 7): S 13,332.50 <br />$ 266,650.00 <br />Accompanying Documentation:, <br />CONTRACTOR'S Certification: <br />The undersigned CONTRACTOR certifies that (1) title to all Work, materials and equipment incorporated in <br />said Work or otherwise: listed in or covered by this Application for Payment will pass to OWNER at time of <br />payment free and clear'. of all iLiens, security interests and encumbrances; (2) all Work covered . by this <br />Application for Payment is accordance with the Contract Documents and not defective; and (3) the labor <br />and materials listed ori this Application;;for Payment have been used In the construction of this Work and <br />payment received 'from the last progress payment has .been used to make payments to all subcontractors, <br />laborers, matertalmen and suppliers except as. listed below <br />Dated I/v7,Sn /// <br />/-7/icy <br />State of rtn< /l <br />Gull Stales Industries, Inc. <br />County of "4 . <br />Subs rlbed and sworn to before me this ;x'SP" �r <br />day rp -AptuA y , ::26 it( <br />./! Q.!c t?ii zc <br />-fqoliry Public U / <br />My Commission expires: --)/V ./�0/i <br />Payment of the above AMOT'bUE THIS APPLICATION is recommended. <br />r41 e <br />li.. 1 • <br />.ia <br />(407}.398.0153 <br />MARIANNE TAGO <br />MY COMMISSION #FF020201 <br />EXPIRES•Mey 21, 2017 <br />Flerl d n No laryS a rvlce.com <br />Dated 4/7/14 <br />M4v e iltrwut ;I/ INEERBy: /�C�/ r P6, <br />ENGINEER <br />EJCDC.No. C -700•E'(2002 Edition) z• <br />Preparedby the Engineers Joint Contract Daarmenls Committee and endorsed byTno Assado1ad General Contractors ofAffiance and the Construction <br />Specification Institute. <br />CONTRACTOR <br />_00800-22 <br />16 <br />