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Contractor's Application for Payment Pelican Pointe Water Service Lateral Replacement Application for Payment No. 1 FINAL For Work Accomplished through the period of 04/30/18 To: Indian River Countv Utilities From: Blue Goose Construction County WIP Project No.: BG 1311 1 Original Contract Price: 2 Net change by Change Orders and Written Amendments (+ or 3 Current Contract Price (1 plus 2): Contractor Purchased Material 4 Total completed and stored to date: 5 Retainage (per Agreement): 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): CONTRACTOR'S CERTIFICATION: 70,809.75 68,330.95 $ 139,140.70 $ 6.990.86 $ 146,131.56 Total Retainage: $ $ 146,131.56 11 146,131.56 UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor and materials listed on this request for 1 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 fog 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 5110/(: STATE OF FLORIDA COUNTY OF ST LUCIE B: 44i:4� (CONTRACTOR(- must be &gfied by an Officer of the Corporation) Greg Hampton - Controller Print Name and Title r Before me, a Notary Public, duly commissioned, qualified, and actin per grally appeared e qkkv, ('\, who being by me first duly sworn upon oath, says that he/she is the C � 'er of the CONTRAC R mentioned 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; and that all of the statements contained herein are true, correct, and complete. Subscribed and sworn to before me this `t day of mit 2018. r\ is personally known to me or has produced as identification. NOTARY PUBLIC: �t Printed name: ,P,• Commission No.: F945828 Commission Expiration: EWpIREg; December 22, 2019 erv+titets =� A�.r0..•' Bon 00 1 RJU Page 1 Pay Application 1