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SECTION 00622 - Contractor's Application for Payment <br />CR 512 Resurfacing (East Bound Only) <br />(Roseland Road to Easy Street) <br />1) Attach detailed schedule and copies of all paid invo <br />Original Contract Price: I <br />v. %.0UNIG,11L WWIMlWL J .1— % . —p <br />4. Total completed and stored to date: <br />5. Retainage (per Agreement), <br />)C)C <br />6. Total completed and stored to date <br />17. Less previous Application for Paymi <br />CONTRACTOR'S CERTIFICATION: <br />ration for Payment No. <br />Total Retainage: $ <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 />00= - Contractoes Application for Payment - 03-10 rev.doc <br />—.— --l"......, I nM1t.Q1nM MPMF=�TM1132-CR 512 Ebnd ftewgfacing RcsWand Rd to Easy St -SEE PROD 0926Mn*rACorZad Do=mentsV0=- Contract&s 23 <br />SrneadSoft Reprint Date: Wednesday, December 14, 2016 - 11:52:27 - BCC:1826, Attachment Id 1, Page 23 <br />