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Page 4 of 5 ; <br />;I. <br />CERTIFICATION OF ENGINEER: <br />I certify that I have reviewed the above and foregoing Periodic Estimate for Partial <br />Payment; that to the best of my knowledge and belief it appears to be a reasonably <br />accurate statement of the work performed and/or material supplied by the Contractor. I am <br />not certifying as to whether or not the Contractor has paid all subcontractors, laborers, <br />materialmen and suppliers because I am not in a position to accurately determine that <br />issue. <br />Dated <br />SI ATURE <br />CERTIFICATION OF INSPECTOR: <br />I have checked the estimate against the Contractor's Schedule of Amounts for Contract <br />Payments and the notes and reports of my inspections of the project. To the best of my <br />knowledge, this statement of work performed and/or materials supplied appears to be <br />reasonably accurate, that the Contractor appears to be observing the requirements of the <br />Contract with respect to construction, and that the Contractor should be paid the amount <br />requested above, unless otherwise noted by me. I am not certifying as to whether or not <br />the Contractor has paid all subcontractors, laborers, materialmen and suppliers because I <br />am not in a position to accurately determine thA issue. <br />Dated VIIOI17 <br />SIGNATURE <br />[The Remainder of This Page Was Left Blank Intentionally] <br />Pay Application No. 12 <br />00822-4 <br />\VCERN"C1UsersU(em V3esldoplPROJECTS12015 Pmledsl= Sidewalks 87th + 91 sW=1dng%Pey Appiication No. 12fty AppilwNon Na 12.doc Rev. 05MI <br />