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Page 4 of 5 <br /> CERTIFICATION OF ENGINEER: <br /> I certify that I have reviewed the above and foregoing Periodic Estimate for Partial <br /> Payment; that to the best of my knowledge and belief it appears to be a reasonably <br /> accurate statement of the work performed and/or material supplied by the Contractor. I am <br /> not certifying as to whether or not the Contractor has paid all subcontractors, laborers, <br /> materialmen and suppliers because I am not in a position to accurately determine that <br /> issue. <br /> Dated <br /> SIGNATURE <br /> CERTIFICATION OF INSPECTOR: <br /> I have checked the estimate against the Contractor's Schedule of Amounts for Contract <br /> Payments and the notes and reports of my inspections of the project. To the best of my <br /> knowledge, this statement of work performed and/or materials supplied appears to be <br /> reasonably accurate, that the Contractor appears to be observing the requirements of the <br /> Contract with respect to construction, and that the Contractor should be paid the amount <br /> requested above, unless otherwise noted by me. I am not certifying as to whether or not <br /> the Contractor has paid all subcontractors, laborers, materialmen and suppliers because I <br /> am not in a position to accurately determine that issue. <br /> Dated <br /> SIGNATURE <br /> [The Remainder of This Page Was Left Blank Intentionally] <br /> 00622-Contractor's Application for Payment-03-10 rev.doc <br /> 00622-4 <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 />