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'-_.. _.�. .... a ....::::....-.... ..... .. _.... <br />Page 4of5 <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 />SIGNATURE <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, matenalmen and suppliers because I <br />am not in a position to accurately determine that issue. <br />Dated <br />SIGNATURE <br />[The Remainder of This Page Was Left Blank Intentionally] <br />00622. - Contractor's Application for Payment - 03-10 rev <br />00622.-4 <br />F:1Publtc WorksIENGINEERING DIVISION PROJECTSA736. IRC Hea(Ih Department Roof Replacement PigeUV-AdmfMB1d DocumentsWaster Contract DoeumentAO0622 - <br />Contractor's Application for Payment - o3.10 rev.doc Rev. 05101 <br />