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01/08/2019
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01/08/2019
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Last modified
12/31/2019 11:14:42 AM
Creation date
2/19/2019 9:38:57 AM
Metadata
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Meetings
Meeting Type
BCC Regular Meeting
Document Type
Agenda Packet
Meeting Date
01/08/2019
Meeting Body
Board of County Commissioners
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Page 2 of 5 <br />2. Updated Construction Schedule per Specification Section 01310, and <br />Dated //A fig By: <br />(CONTRACTOR — muster signed by <br />an Officer of the Corporation) <br />,e,o eser - k ms <br />Print Name and Title <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <br />Before me, a Notary Public, duly commissioned, qualified, and acting, personally appeared <br />RPer74 (ter , who being by me first duly sworn upon oath, says that he/she is the <br />v: co- 6r16.47 j- of the CONTRACTOR mentioned above and that he/she has been duly <br />authorized to act on behalf of it, and that he/she executed the above Contractor's Application for <br />Payment and Contractor's Certification statement on behalf of said CONTRACTOR; and that all of <br />the statements contained herein are true, correct, and complete. Subscribed and swom to before <br />me this n 4, day of 2' , 20 ie . <br />Ao tf (Z <br />is personally known to me or has produced <br />as identification. <br />(SEAL) <br />p� Y Put. <br />LARISA DIM PELKEY <br />Commission:* GG 157707 <br />Expires January 22, 2022 <br />Boded five Budget Notary <br />Please remit payment to: <br />Contractor's Name: <br />NOTARY PUBLIC:,/ <br />Printed name: / n-, 7 - p,- 17/ -51 -- <br />Commission No.: �q /5-77 <br />Commission Expiration: .0/. <br />/nfc. <br />Address: 9 4 74- .2r, - a .2 <br />********* <br />*A AA AAAA***-* AA A**AAAAA k********** <br />****************** <br />[The remainder of this page was left blank intentionally] <br />00622 - Contractor's Application for Payment -04-final <br />00622 - 2 <br />H:\IXCEL\CURRENT JOBS - 200'S\21501100622 - Contractors Application for Payment -04finaLdoc Rev. 05/01 <br />101 <br />
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