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s 't SECTION 00622 - Contractor's Application for Payment Gifford Neighborhood 4P Street Beautificatlon Project Application for Payment No, 12rev For Wo c_cqmP-IIsh§§ throggh the Mriod of 06/26/16 through 10/25/16 To: Indian River County (OWNER} From. - (CONTRACTOR) SUNSHINE LAND DESIGN, INC. -- Bid No.: 2015040 Project No.: 1506_ 1) Attach detailed schedule and claques of all paid Invoices. 1. Original Contract Price: $1,306,877.14 2. Net change by Change Orders and Written Amendments (+ or $ 626,472.87 3, Current Contract Price (1 plus 2): $ 1.933,350.01 4. Total completed and stored to date: $ 1,12,084.29 5. Retainage (per Agreement): e' completed Work: % of retainage: $ Total Retainage: $ 6. Total completed and stored to date less retainage (4 minus 5): $ 1,812,084.29 7. Less previous Application for Payments: $ 1.653,505.95 8. DUE THIS APPLICATION 16 MINUS 7): 158 578.34 c_ONTMCTORIS CERTIFJC TA ION: UNDER PENALTY OF PERJURY, the unlersigned CONTRACTOR certifies that (1) the labor and materials fisted on this request for payment have been used in the construction of this Work; (2) payment received from the last pay request hay: been used to make payments to all subcontractors, laborers, materiaimen 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 tI• i OWNER. Attached to or submitted with this form are: 1. Signed release of lien forms (partial or final as applicable) from all subcontractors, laborers, materialmen and suppliers except as listed on Attachment A, together with an explanation as to why any release of lien form is not Included; 00632 - Conuaci to Application for Payment - o3-10 rev 00622 -1 FV W10 WvkMENOM1EERM OMMON PROJECr8ti SMCMW W Ne+� $51h at 8eWB cMmnWm V1W deamtentatN 01nU d GWIMUMM a App keWn for "M - 03.10 rov.doa Roy. 06M P23