04/08/2014 - Laserfiche WebLink

Home Browse Search

Page 4 of 5 CERTIFICATION OF ENGINEER: I certify that I have reviewed the above and foregoing Periodic Estimate for Partial Payment; that to the best of my knowledge and belief it appears to be a reasonably accurate statement of the work performed and/or material supplied by the Contractor. I am not certifying as to whether or not the Contractor has paid all subcontractors, laborers, materialmen and suppliers because I am not in a position to accurately determine that issue. Dated SIGNATURE CERTIFICATION OF INSPECTOR: I have checked the estimate against the Contractor's Schedule of Amounts for Contract Payments and the notes and reports of my inspections of the project. To the best of my knowledge, this statement of work performed and/or materials supplied appears to be reasonably accurate, that the Contractor appears to be observing the requirements of the Contract with respect to construction, and that the Contractor should be paid the amount requested above, unless otherwise noted by me. I am not certifying as to whether or not the Contractor has paid all subcontractors, laborers, materialmen and suppliers because I am not in a position to accurately determine that issue. Dated 3:/// 3/1 NATURE *******lrat******* *****************Irk**** * ,t******* *Int*******1rr***** * ,r*#A*** ******************r [The Remainder of This Page Was Left Blank Intentionally] 00622 - Contractors Application for Payment - 03-10 rev 00622-4 F,1PubHIc Works\ENGINEERING DIVISION PROJECTS11102-0Id Dixie Hwy Swk 8th St to SR 60- AP virrimlbid documents Waster Contract Documents \00622 - Contractor's Application for Payment - 03-10 rev.doc Rev. 05101 REMIT PAYMENT TO: TERMS: A-1 FLORIDA SOD, INC. 150 DEEN STILL ROAD DAVENPORT, FL 33897 WLFMSWHI DIMENSION BUSINESS FORMS 6 PRINTING 901-7204B49 WZ3/82 C- 1C PRINT ED IN U. S.A. 71 SUBTOTAL TAX RETAINAGE LESS DEPOSIT AMOUNT DUE PREVOUS &LLtN TOTAL.BILLINGS $2,697.00 $127.89 $0.00 $2,824.89 72