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SECTION 00622 - Contractor's Application for Paymen <br />Vero Lake Estates Asphalt Millings Project (Phase I) <br />Application for Payme <br />For Work Accomplished through the period of through <br />t No. <br />To: Indian River County (OWNER) <br />From: (CONTRACTOR) <br />Bid No.: 2015010 <br />Project No.: 1314 <br />1) Attach detailed schedule and copies of all paid invoices. <br />1. <br />2. <br />3. <br />4. <br />5. <br />Original Contract Price: <br />Net change by Change Orders and Written Amendments (+ or -): <br />Current Contract Price (1 plus 2): <br />Total completed and stored to date: <br />Retainage (per Agreement): <br />% of completed Work: <br />% of retainage: $ <br />$ <br />Total Retainage: $ <br />6. Total completed and stored to date less retainage (4 minus 5): $ <br />7. Less previous Application for Payments: <br />8 DUE THIS APPLICATION (6 MINUS 7): <br />CONTRACTOR'S CERTIFICATION: <br />UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that <br />and materials listed on this request for payment have been used in the construction of <br />payment received from the last pay request has been used to make payments to all su <br />laborers, materialmen and suppliers except as listed on Attachment A, below; (3) titl: <br />materials and equipment incorporated in said Work or otherwise listed in or co <br />Application for Payment will pass to OWNER at time of payment free and clear of all L <br />interests and encumbrances (except such as are covered by a Bond acceptable <br />indemnifying OWNER against any such Lien, security interest or encumbrance); <br />covered by this Application for Payment is in accordance with the Contract Docum <br />defective; and (5) If this Periodic Estimate is for a Final Payment to project or improve <br />certify that all persons doing work upon or furnishing materials or supplies for t <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 be -n paid and <br />discharged, and that I have no claims against the OWNER. <br />(1) the labor <br />his Work; (2) <br />bcontractors, <br />of all Work, <br />ered by this <br />ens, security <br />to OWNER <br />(4) all Work <br />-nts and not <br />ent, I further <br />is project or <br />Attached to or submitted with this form are: <br />1. Signed release of lien forms (partial or final as applicable) from all subcontract rs, laborers, <br />materialmen and suppliers except as listed on Attachment A, together with an e planation as <br />to why any release of lien form is not included; <br />00622 - Contractor's Application for Paym <br />nt - 03-10 rev.doc <br />00622 - 1 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1314-107th Ave Milling_90th St to 94th St\Admin\bid documents\Master Contract Documents\00622 - t♦ontractors Application <br />for Payment - 03-10 rev.doc Rev. 05/01 <br />