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SECTION 00622 - Contractor's Application for FayME <br />South County Regional Park Multi -Purpose Fields <br />From: Barth (CO <br />Bid No.: 2013009 <br />Project No.: 1126 <br />1 Original Contract Price: <br />2. Net change by Change C <br />3. Current Contract Price (1 <br />4, Total completed an <br />5. Retainage (per Agr <br />+ or - <br />pleted Work: <br />1,862L174.3 <br />-258,151.59 <br />1,576,881.12 <br />U. futal $ 1,446,392.2& <br />7. Less previous Application for Payments: - <br />130,488.83 <br />CONTRAc rOR'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 />listed on Attachment A, below; (3) title of all Work, <br />laborers, materialmen and suppliers except as Work or otherwise listed in or covered by this <br />materials and equipment incorporated in said <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 Art, 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 - Contractor's <br />UPurpose I enls=622 - Contractor's Application <br />rn,PublicWorksiENGINEERING DIVISION PROJECTSM26- RFP South Co Park MuM Fields�AdmimWld documentsxContrect Dowm <br />for Payment - 03-10 rev.doo Rev. 05101 <br />SmeadSoft Reprint Date: Wednesday, December 14,-2016 - 11:53:13 - BCC:1826, Attachment Id 1, Page 48 <br />