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SECTION 00622 - Contractor's Application for Payment <br /> SOUTH COUNTY PARK GENERAL USE FIELD <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.: 2016048 <br /> Project No.: 1425 <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-Contractors Application for Payment-03-10 rev <br /> 00622-1 <br /> F-%Public Works\ENGINEERING DIVISION PROJECTS\1425-S County Park-General Use FieldlAdminlbid documentsXMaster Contract Documents\00622-Contractor's Application for <br /> Payment-03-10 rev.doc Rev 05/01 <br />