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11 <br />t1 <br />Dated Qvgtks\ , ao) t-( B <br />STATE OF FLORIDA <br />COUNTY OF miampfttv-pj <br />Before me a Votary Public, duly commissioned, qualified, and acting, personally appeared <br />• \-o f�, who being by me first duly sworn upon oath, says that J/she is the <br />cst \1�StSt -vit of the CONTRACTOR mentioned above and that he has been duly <br />authorized to act on behalf of it, and. that( to 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 tv,sq 1i5- , 20 \4. <br />• 5 cc�� 1 S'o� ] (� J is ersonally known to me <br />as idents ation- <br />(CO RAC • R -- must be signed by <br />an Officer of the Corporation) jt <br />• S( o,6) e� / U � cEa � Q..Q5,C <br />Print Name and Title <br />>`v,c3 L. $q�Po�< <br />(SEAL) �; issrry ;3% <br />w • 2; 19, F%o .• r <br />00.6.0 <br />3EE 154184a <br />• Qq9.1;(9:41;;(61; I.S71:11jr) gt7i;k()::".4z: <br />NOTARY PUBLIC: <br />Printed name: <br />or has produced <br />Commission No.: E� 15y r <br />Commission Expiration: <br />IL) <br />***YU*Yt*yt***irlr*******i****lhtiF*ktk**iF*lFie****# k*******************Irk*****k*******************Ir********** <br />[The remainder of this page was left blank intentionally] <br />00622 - 2 <br />F:1Public WorkeNENGINEERINO DIVISION PROJECTS113024R Blvd Resutacing (SCOP) liS1 to 17th StlAdmimlbid documents400622 - Contra toev Application for Payment - 03.10 <br />rev,doc Rev. 05!01 <br />00622 - Contractor's Application for Payment - 03-10 rev.doc <br />160 <br />