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._`� nit <br />SECTION 00622 - Contractor's Application for P,aymfl 2 8 2016 <br />Gifford Neighborhood 464h Street Beautiification,Pro ct <br />�A I Application for Payment No. 12rev . <br />For Work Accomptishga through th§period of 06126116 through 10/25/16 <br />To: Indian River County (OWNER) <br />From: (CONTRACTOR) SUNSHINE LAND MIGN, INC. <br />Bid No.: 2016040 <br />Project No.: 15W <br />1) Attach detailed schedule and copies of all paid Invoices. <br />1. <br />Original Contract Price: <br />11,306,877.14 <br />2. <br />Net change by Change Orders and Written Amendments (+ or r): <br />626,472.87 <br />3. <br />Current Contract Price (1 plus 2): <br />1,933.350.01 <br />4. <br />Total completed and stored to date: <br />$ 1,812,084.29 <br />5. <br />Retainage (par Agreement): <br />% C'. completed Work: <br />of retainage: <br />$ <br />Total Retainage: <br />$ <br />6. <br />Total completed and stared tti date less retainage (4 minus 5): <br />1.812,084.29 <br />7. <br />lass previous Application for Payments: <br />$ 1.653.505.95 <br />g. <br />DUE THiS APPLICATION (6 MINUS 7): <br />158.578.34 . <br />CQMTTOR'S CERT FIfiMt0N: <br />UNDER PENALTY OF PERJURE', 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 he6 been used to make payments to all subcontractors, <br />laborers, materilalmen 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 tl-s 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 />Ale <br />(l <br />0882'2 - CnnbadofsAPPn radon ter Payr&O rev <br />00822 - i <br />P: A6k v NGINEMN0 01MON PR0JE-CM1M6-ae«d NeOb~ 441n seEeauUAawn,A Wta doasmawow Cha QuC�== • cwhdaes <br />Aplllftft rot Pny+mM . tX IO rmv.doafty. OW <br />P24 <br />