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CERTIFICATION OF ENGINEER: I certify that I have- reviewed the above' and foregoing Periodic Estimate for Partial Payment;; that to: the best, of my knowledge and :belief it appears to be: a reasona_ b I y accurate statement of-the work.performed,and/ot Material supplied-by the Contractor.. I am not certifying as to whether or- not the Contractor has paid all subcontractors-, laborers, materialhien and suppliers because I am not in a: position to accurately determine that issue. D_"ated SIGNATURE CERTIFICATION OF INSPECTOR:. 1 have checked the estimate a' ainst,the Contractor's Schedule of Amounts-for Contract Payments and. the notes and reports of my inspections of the. project. To the best of my knowledge, this- statement of work performed and/or materials supplied appears. to, be reasonably accurate, that the Contractor appears to be observing the requirements of the Contract-.with respect to construction, ,and that the Contractor should be paid the amount requested above, unless otherwise noted by me. I am not,certifying a$ to whether or not the Contractor haspaid all subcontractors, laborers;,materialmen and suppliers because 1 am not in a.position to accurately determine that`issue-. Dated- SIGNATURE [The Remainder of This;Page.Was Left Blank Intentionally] 00622 Contractors Application for-PayMbfit'-03-10 rev _ 00622 ;F:1PublIe WorkslENGINEERING DIVISION PROJECTS113304.R.C:Goune Transfer HubWdminWid'doamentsWaster Contract Documents100522=Contractor's Application for Payment'03-10 rev.doc Rev.05101.