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SECTION 00622 - Contractor's Application for Payment <br /> Indian River Boulevard Resurfacing <br /> (41St Street to 53rd Street) <br /> Application for Payment No. 3 <br /> For Work Accomplished through the period of 3/1/2013 throusah 3/31/2013 Final <br /> To: Indian River County(OWNER) <br /> From: Community Asphalt Corp. (CONTRACTOR) <br /> Bid: 2013007 <br /> Project: 1131 <br /> 1) Attach detailed schedule and copies of all paid invoices. <br /> 1. Original Contract Price: $776.945.42 <br /> 2. Net change by Change Orders and Written Amendments(+ or-): L0 <br /> 3. Current Contract Price(1 plus 2): $776,945.42 <br /> 4. Total completed and stored to date: $730.416.15 <br /> 5. Retainage(per Agreement): <br /> 100%of completed Work: $730,416.15 <br /> 0% of retainage: $0 <br /> Total Retainage: 30 <br /> 6. Total completed and stored to date less retainage(4 minus 5): $730.416.15 <br /> 7. Less previous Application for Payments: $599,874.96 <br /> 8. DUE THIS APPLICATION 6 MINUS 7): $130.541.19 <br /> ., CONTRACTOR'S CERTIFICATION: <br /> UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor <br /> and materials listed on this request for payment have been used in the construction of this Work; (2) <br /> payment received from the last pay request has been used to make payments to all subcontractors, <br /> laborers, materialmen and suppliers except as listed on Attachment A, below; (3) title of all Work, <br /> materials and equipment incorporated in said Work or otherwise listed in or covered by this <br /> Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security <br /> interests and encumbrances (except such as are covered by a Bond acceptable to OWNER <br /> Indemnifying OWNER against any such Lien, security interest or encumbrance); (4) all Work <br /> covered by this Application for Payment is in accordance with the Contract Documents and not <br /> defective; and (5) If this Periodic Estimate is for a Final Payment to project or improvement, l further <br /> certify that all persons doing work upon or furnishing materials or supplies for this project or <br /> improvement under this foregoing contract have been paid in full, and that all taxes imposed by <br /> Chapter 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and <br /> discharged, and that i have no claims against the OWNER. <br /> Attached to or submitted with this form are: <br /> 1. Signed release of lien forms (partial or final as applicable)from all subcontractors, laborers, <br /> materialmen and suppliers except as listed on Attachment A, together with an explanation as <br /> to why any release of lien form is not included; <br /> Page 2 of 6 <br /> 00622-Contractors Application for Payment-03-10 rev Pay App#3 Indian River Blvd <br /> 00822-1 <br /> V:W381Pey ApplicationsM22-Contractors Appitcaton for Payment-03-10 rev Pay App#3 Indian Ricer Blvd.dm Rev.0501 64 <br />