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APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G703 PAGE 1 OF 2 PAGES DEDUCTIONS US 1 Air Release Valve and 24' Forcemain b. of Stored Stored Material S Replacement 0.00 TO CONTRACTOR: PROJECT: APPLICATION NO; TWO Distribution to: Indian River County -Engineering Division INVOICE NO: 2 Owner 1801 27th Street Pro)ecl 0 Bid If 2018-047 _ Architect Vero Beach, FL 32960 07131/18 128,658.00 Attn: Mr. John Boyer, P.E. PERIOD T0: 9130/2018 _ Contractor 0.00 Contract date: 5/1/2018 _ FROM (CONTRACTOR): VIA (ENGINEER): S 103.855.32 Johnson -Davis Inc. Contract: _ 604 Hillbralh Drive Net change by Change Orders 114,658.00 S - Lantana, FL 33462 CONTRACT FOR: US 1 Air Release Valve and 24' Forcemain Replacement CONTRACTOR'S CERTIFICATE FOR PAYMENT Application is made for Pi menL as shown below, in connection with the Contract. Continuation Sheets, AIA Document G703, is attached. CHANGE ORDER SUMMARY Change Orders approved in ADDITIONS DEDUCTIONS previous months by Owner b. of Stored Stored Material S TOTAL 0.00 0.00 Approved this Month 0.00 Number Date Approved S Change Order A'01 07131/18 128,658.00 (Line 4 less Lina 5 Total) .Change Order #02 10/16/18 0.00 (14,000.00) FOR PAYMENT (Line 6 from prior Certificate) 0.00 S 103.855.32 8. CURRENT PAYMENT DUE TOTAL 128,658.00 14,000.00 Net change by Change Orders 114,658.00 The undent9mil Contactor Canteas that to the best of the Contractoes K-Medpe. Intonnaton and boltet the want caveted by tris Apperallon fa Payment has been completed In attadansb with the COMCI DOCUlnents. W I all ametxln tum been pald by the Contractor Ix wank fa emi•.h PI.A.5 UnIkOros far Payment were Usued and payments lecehed from the Owed, and Cal anent Pa)mem atlaA herein Is now ddo. CONTRACTOR: Johnson -Davis, Inc. By: CERTIFICATE FOR PAYMENT Date: 10/212018 In accavdanmwith tw Convact Donhmems, based on—stte obser !iW3 and vro dem comprlsuV the above application. the AreheSa cenf.,es to Me Owner Met to the best of Uro ArcNtect'f knd *dge, Information and Naef the work halt progrossed as indicated, the quality, of Ne wOn, la In aeeardame with the Conoad DOCnmMte, and trio Cormocte, Is oneted to payment of M AMOUNT CERTIFIED. 1. ORIGINAL CONTRACT SUM 2. Net change by Change Orders 3. CONTRACT SUM TO DATE (Line 1 ♦ 2) 4. TOTAL COMPLETED 8 STORED TO DATE (Column G on G703) 5. RETAINAGE 124.000.00 114,658.00 238.658.00 238.658.00 e. 0% Retainage S (Column 0 + E on G703) b. of Stored Stored Material S (Column F on G703) Total Retainage (Line Sa - 5b or Total in Column I of G703) S 6. TOTAL EARNED LESS RETAINAGE S 238.658.00 (Line 4 less Lina 5 Total) 7. LESS PREVIOUS CERTIFICATE FOR PAYMENT (Line 6 from prior Certificate) S 103.855.32 8. CURRENT PAYMENT DUE 5 134.002.00 9. BALANCE TO FINISH S - (Line 3less Line 4) Stale of: FLORIDA County of: Palm Beach Subscribed and swam to before me this 02nd dayol October 2018 o�y%I po" IARISADITU PELKEY Commission g GG 157707 Notary Public: f My Expires January 22,2022 Commission expires: 01-22.2022 +iFD' M1arc' Bablod0iifas;m ,t,ryS'nsoo: (Attach explanation If amount certified differs from the amount applied for.) ARCHITECT: By. Date: This ceNfcato Is not neyodable. The AMOUNT CERTIFIED Is payable omy to the Convector named herein. tswance, payment and eaapmnod of payment ae wIMW pre w= to any rghts of the Owner of Caaravw under tts Convect 107