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SECTION 00622 - Contractors Application for Payment <br />CR512 Resurfacing from 1250, Avenue to I-85 <br />Application for Payment No. 4 <br />Fir Work ACcomi tted throuch the Made 04/01Q6 through 04/30/16 FINAL <br />To: 1 ddtart River ggg ft.(OWNM) <br />From: Range* Construction Industries, Inc. (CONTRACTOR)Bid No.: 003 <br />Project No.: 1304 <br />1) Attach deWied schedule and copies of all paid lnvok*& <br />1 • Original Contract Price: $ 787,526.59 <br />2. Net change by Change Orders and Written Amendments (+ or -): $ 56,204.90 <br />3. Current Contract Price (1' plus 2): $ 843,731.49 <br />4. Total completed and stored to date: $ 793,399.44 <br />5. Retainage (per Agreement): <br />_L0_0% of completed Work <br />96 of retainage: $ <br />Total Retainage: $ <br />6. Total completed and stored to date less ratainage (4 minus 5): $ <br />7. Less previous Application for payments: $ 660232.30 <br />& DUE TIM APPLICATION (6 MINUS 71: g 133,167.14 <br />UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the tabor <br />and materials listed on this request for payment have been used In the construction of this Worlq (2) <br />payment received from the last pay request has been used to mails payments to all subcontractors, <br />laborers, materialmen and suppliers except as listed on Attachment A, below, (3) tide of all Work, <br />materI mW equipment incorporated In said Work or of wwisi listed In or covered by this <br />Application for Payment will pass to OWNER at time of payment free and pear of all Liens, security <br />interests and encurnbranoes (except such as are oovared by a Bond acceptable to OWNER <br />indemnifying OWNER against any such Lien,. security Interest or encumbranoe); (4) all Work <br />covered by this Application for Payment Is to accordance with the Contract Documents and not <br />l itre; and (5) If -this Perk4c Estimate Is for a Final Payment to project or Wgviement, i further <br />certify that all persons doing work upon or furnishing materdWs or suppiles for this project or <br />Improvement under this foregoing contact have been paid in foil, artd that ap tropes 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•daims against the OWNER. <br />Atb dvd to or submitted wb this fort 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 AtiadmMit A, together with an explanation as <br />--to why any release of lien form Is not inckided; <br />OM2 -1 00622 - CO&DCbes Apps for Payment - 0310 rev <br />91PWbWar1e 92{0ONW10%PROdECY3IW R512Rmxf9XML1MArel01661A iedponet65MrlerCbrUmiOeam 0ta2-Cd COoro <br />Npy9eatton ferPeyment- tla10 rade rbst 0541 <br />71 <br />