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2013-086A
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2013-086A
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Last modified
1/12/2017 3:00:06 PM
Creation date
3/3/2016 10:30:12 AM
Metadata
Fields
Template:
Official Documents
Official Document Type
Contract
Approved Date
05/07/2013
Control Number
2013-086A
Agenda Item Number
8.P.
Entity Name
Ag-Scape Services contract documents and specifications
Subject
Oslo Road Culvert Replacement
Project Number
1306
Bid Number
2013034
Supplemental fields
SmeadsoftID
11935
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SECTION 00622 - Contractor's Application for Payment <br /> OSLO ROAD CULVERT REPLACEMENT <br /> Application for Payment No. <br /> For Work Accomplished through the period of through <br /> To: Indian River County (OWNER) <br /> From: (CONTRACTOR) <br /> Bid No.: 2013034 <br /> Project No.: 1306 <br /> 1) Attach detailed schedule and copies of all paid invoices. <br /> 1. Original Contract Price: $ <br /> 2. Net change by Change Orders and Written Amendments (+ or-): $ <br /> 3. Current Contract Price (1 plus 2): $ <br /> 4. Total completed and stored to date: $ <br /> 5. Retainage (per Agreement): <br /> • of completed Work: <br /> • of retainage: $ <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 (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, I 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 /> 00622-Contractor's Application for Payment-03-10 rev.doc <br /> 00622-1 <br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1306 Oslo Road(E of 15th Ave SW)Pipe Culvert Improvement\Admim\bid documents\00622-Contractors Application for <br /> Payment-03-10 rev.doc Rev.05/01 <br />
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