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APPLICATION FOR PAYMENT N0. �1 '� �„vA4_ r C -DIVED <br />To: Indian River County Department of Utilities Services (OWNER) OCT :2 7 2016 <br />From: fjAftV- CB v', orzTTe -TNh t',,v c- (CONTRACTOR) BY: <br />Contract: KI K K, ROAloA& <br />Project: Blue Cypress New Replacement Package WWTF <br />OWNER's Contract No. UCP # 4107. ENGINEER's Project No. 1341 <br />For Work accomplished through the date of: 'Tilly 29T201& <br />2. <br />3. <br />4. <br />5. <br />L:1 <br />8. <br />Original Contract Price: <br />Net change by Change Orders and Written Amendments (+ or -) <br />Current Contract Price (1 plus 2): <br />Total completed to date <br />Retainage (per Agreement): <br />_ 0 % of completed Work: <br />Total Retainage: <br />Total completed to date less retainage (4 minus 5): <br />Less previous Application for Payments: <br />$ 3y� oou <br />$ 3 op <br />$ s '•a 3 <br />$ <br />_.'$� l � 3 <br />$_26,00.9-7 <br />DUE THIS APPLICATION (6 MINUS 7): $_ 4 <br />Accompanying Documentation: <br />CONTRACTOR'S Certification: <br />The undersigned CONTRACTOR certifies that (1) title to all Work, materials and equipment incorporated in <br />said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of <br />payment free and clear of all Liens, security interests and encumbrances; (2) all Work covered by this <br />Application for Payment is in accordance with the Contract Documents and not defective; and (3) the labor. <br />and materials listed on this Application for Payment have been used in the construction of this Work <br />and payment received from the last progress payment has been used to make payments to all <br />subcontractors, laborers, material, men and suppliers except as listed below: <br />Dated 1 I I V1 1(o <br />State of G L <br />County of LA f-5 <br />Subscribed and sworn to before me this <br />day of . T"A -i _, 20A <br />Law <br />Notary Public <br />My Commission expires:�' Ito a <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated <br />1 — L--- - ` - -ENGINEER <br />By: Lar 1 i1. Nla.sW IPf, PE&&F..Pl-e3id e4 <br />EJCDC No. C -700-E (2002 Edition) /�!`QS}��p�� - /'O'e-r VCC <br />Prepared by the Engineers Joint Contract Documents Committee and endorsed by a Associate eneral Contractors or Am rtca and the Construction <br />Spec&ation Institute. <br />��SDS <br />00810-s 83 <br />�:EXPIRES: <br />MY COMMISIGN / /IFF 160213 <br />N't. <br />September 16, 2018 <br />SW6d Thru Notary Public Undembrs <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated <br />1 — L--- - ` - -ENGINEER <br />By: Lar 1 i1. Nla.sW IPf, PE&&F..Pl-e3id e4 <br />EJCDC No. C -700-E (2002 Edition) /�!`QS}��p�� - /'O'e-r VCC <br />Prepared by the Engineers Joint Contract Documents Committee and endorsed by a Associate eneral Contractors or Am rtca and the Construction <br />Spec&ation Institute. <br />��SDS <br />00810-s 83 <br />