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Page 4 of 5 <br />CERTIFICATION OF ENGINEER: <br />certify that l 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 16--1� - zws �t-� `1.4_t dj'— <br />SIGNATURE <br />CERTIFICATION OF INSPECTOR: <br />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 ovhe <br />Contract with respect to construction, and that the Contractor should be paid the amount <br />requested above, unless otherwise noted by me. l 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 that issue. <br />Dated. LO — t 7 / <br />"- <br />S(GNATURE <br />[The Remainder of This Page Was Left Blank Intentionally]. <br />00622 -4 J <br />RETAINAGE COVEY J13E. <br />MIDocumenlsMORK FILESXCR510 85TH STRFFT RIM4TTI IRM I ANF FVTFMCInM1PAV noci $PATIMImO AIAOAnc -C6 —C a.... o_..-- <br />