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APPLICATION FOR PAYMENT NO. 1 FINAL To: Indian River County Utilities From: Blue Goose Construction, LLC (CONTRACTOR) Contract: WA No. 2018-001 PO #: 34,604.70 Project: 1319 -128th Ct Water Main Extension For Work completed through the date of April 2018 1 Original Contract Price: $ 35,634.06 2 Net change by Change Orders and Written Amendments (+ or -): (4,988.36) do- ntractor^Purchased Material w 3,959.001 3 Current Contract Price (1 plus 2) 34,604.70 4 Total completed and stored to date: 34,604.15 5 Retainage (per Agreement) 30,645.70 of completed work of stored material $ - Total Retainage: - 6 Total complete and stored to date less retainage (4 minus 5) 34,604.70 7 Less previous Application for Payments - 8 DUE THIS APPLICATION (6 MINUS 7) $ 34,604.70 Accompanying Documentation: CONTRACTOR'S Certification: The undersigned CONTRACTOR certifies that (1) all previous progress payments received from OWNER on account of Work done under the Contract referred to above have been applied on account to discharge CONTRACTOR' legitimate obligations incurred_in.connection with Work covered by prior Applications for Payment numbered 1 through 1 inclusive; (2) 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); and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective. Dated: :S Ll? l8 State of X10 r i d.Q County of SLkscribed and sworn to before me this Blue Goose Construction LLC CONTRACTOR By: ^i Greg Hampton, Contrdi err 10-03 day of /"IGI , 2017 ��vyv—may �w MUhiZ Notary Public Q t NOTARY PUBLIC My Commission expires: STATE OF FLORIDA Expires 4/23/2022 Payment of the above AMOUNT DUE THIS APPLICATION is recommended. Dated: ENGI R By; A) u Prepared by the engineers Joint Contract Documents Committee and endorsed by The Associated General Contractors of America and the Construction Specification Institute.