06/11/2019 - Laserfiche WebLink

Home Browse Search

CONTRACTOR'S CERTIFICATION: UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that all previous progress payments received on account of the Work have been applied on account to discharge CONTRACTOR's specific legitimate obligations associated with prior Applications for Payment. This certification includes, but is not limited to the following statements of fact: (1) the labor and materials listed on this request for 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 for 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 OWNER. Attached to or submitted with this form are: 1. Signed release of lien forms (partial or final as applicable) from all subcontractors, laborers, materialmen and suppliers except as listed on Attachment A, together with an explanation as to why any release of lien form is not included; 2. Updated Construction Schedule per Specification Section 01310, Under oath, I swear that the foregoing statements are true. Dated: May 21, 2019 By: (CONTRACTOR — must be signed by an Officer of the Corporation) Andrew E. Costello / President Print Name and Title STATE OF FLORIDA - COUNTY OF Highlands Before me, a Notary Public, duly commissioned, qualified, and acting, personally appeared Andrew E. Costello, who being by me first duly sworn upon oath, says that he/she is the President of the CONTRACTOR 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 21st day of May, 2019. Andrew E. Costello is personally known to me or has produced as identification. NOTARY PUBLIC: (SEAL) Printed name: _Debra Lynn Falls Commission No.: GG 206329 Commission Expiration: April 11, 2022 **************************************************************************************************** Last Revised 6/20/2017 Attachment 1 00622 - 2 F:\Public Works\KeithM\Stormwater Projects\Main Relief Canal Operation V015-2016 Modifications\Agenda Items\ConveyorsWltachment 1.doc Rev. 05/01 31