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SECTION 00622 - Contractor's Application for Payment 20t'Avenue & 16th Street Intersection Improvements REVISED Application for Payment No 6 For Work Accomplished through the period of 06/01/16 through 08/31/16 To: Indian River County (OWNER) From: Timothy Rose Contracting(CONTRACTOR) Bid No.: 2015037 Project No.: 0225 1) Attach detailed schedule and copies of all paid invoices. 1. Ongmal Contract Prlce: 2. Net change by Change Orders and Written Amendments (+ or 3. Current Contract Price (1 plus 2): 4. Total completed and stored to date: 5. Retainage (per Agreement): % of completed Work: 5% of retainage: Total completed and stored to date less retainage (4 minus 5): Total Retainage: Less previous Application for Payments: 8. DUE THIS APPLICATION (6 MINUS CONTRACTOR'S CERTIFICATION: $1,112,457.78 $1,112,457.78 $1,070.912.48 LO $1,070,912.48 $1,007,079.88 UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor and materials listed on this request for payment have been used in the construction of this Work; (2) payment received from the last pay request has been used to make payments to all subcontractors, laborers, materialmen and suppliers except as listed on Attachment A, below; (3) title of all Work, materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien, security interest or encumbrance); (4) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective; and (5) If this Periodic Estimate is for a Final Payment to project or improvement, I further certify that all persons doing work upon or furnishing materials or supplies for this project or improvement under this foregoing contract have been paid in full, and that all taxes imposed by Chapter 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and discharged, and that I have no claims against the OWNER. CONTRACTOR'S CERTIFICATION: I hereby certify that the labor and materials listed on this request for payment have been used in the construction of this work and payment received from the last request for payment has been used to make payments to all subcontractors, laborers, material men and suppliers, except as noted below. Dated 08/29/16 Timothy Rose Contracting Incorporated (CONTRACTOR) By: State of Florida County of Indian River Subscribed and sworn to before me this 29 day of August 2016 Notary Public: Deborah West My Commission expires: 10/03/19 p *dlEST 904578 2019 oCover Page - Pay App 6.doc Page - - C:\Users\OvmerlDocumenls\20th Ave & 16th Street Intersection Improvements\Cover Page -Pay App 6.doc Rev. 05101 91