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Contractor's Application for Payment 424 22nd Stree SE Sewer Lateral Replacement To: Indian River County Utilities From: Blue Goose Construction PO No. WA 2018-002 Project No.: BG 1325 1 Original Contract Price: 2 Net change by Change Orders and Written Amendments (+ or 3 Current Contract Price (1 plus 2): 4 Total completed and stored to date: 5 Retainage (per Agreement): 0% of completed Work: 0 % of retainage: 6 Total completed and stored to date less retainage (4 minus 5): 7 Less previous Application for Payments: 8 DUE THIS APPLICATION (6 MINUS 7): Application for Payment No. 1 - FINAL For Work Accomplished through the period of 03/16/18 15,000.56 (6,809.31 $ 8.191.25 191.25 Total Retainage: $ - $ 8,191.25 $ 8,191.25 UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor and materials listed on this request for payment have been used in the construction of this Work; (2) payment received from the last pay request has been used to make payments to all subcontractors, laborers, materialmen 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 the OWNER. Dated I ` L By' antfm (CONTRACTO — must b gned by an Officer of the Corporation) Greg Hampton - Controller Print Name and Title STATE OF FLORIDA COUNTY OF ST LUCIE 1 Before me, a Notary Public, duly commissioned, qualified, and acting, per1sppnally appeared, who being by me first duly sworn upon oath, says that he/she is the C6Y�--Wt LR -r- of the CONTRA OR mentione above and that he/she has been duly authorized to act on behalf of it, and that he/she executed the above Contractor's Application for Payment and Contractor's Certification statement on behalf of said CONTRACTOR;1statements containpd herein are true, correct, and complete. Subscribed and swom to before me this 0— day of Y ` 20 L 1 Y bh is personally known to me or has produced 4 as identification. NOTARY PUBLIC: Printed name: 7ERESAGORMAN #FF 945828 Commission No.:d g* EXPIRES: December 22, 2019 r 'Bon ru egry public Underwriters Commission Expiration: qh°O Page 1 Pay Application 1