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SECTION 00622 - Contractor's Application for Payment <br />INDIAN RIVER BOULEVARD AND GRAND HARBOR BOULEVARD <br />To: <br />From: <br />Project No <br />Bid No.: <br />SIGNALIZATION <br />Application for Payment No. <br />For Work Accomplished through the period of through <br />Indian River County (OWNER) <br />IRC -1806 <br />2019076 <br />(CONTRACTOR) <br />1 <br />1) Attach detailed schedule and copies of all paid invoices. <br />1. Original Contract Price: $ <br />2. Net change by Change Orders and Written Amendments (+ or -): $ <br />3. Current Contract Price (1 plus 2): $ <br />4. Total completed and stored to date: $ <br />5. Retainage (per Agreement): <br />% of completed Work: <br />% of retainage: $ <br />Total Retainage: $ <br />6. Total completed and stored to date less retainage (4 minus 5): $ <br />7. Less previous Application for Payments: $ <br />8. DUE THIS APPLICATION (6 MINUS 7): $ <br />CONTRACTOR'S CERTIFICATION: <br />UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor <br />and materials listed on this request for payment have been used in the construction of this Work; (2) <br />payment received from the last pay request has been used to make payments to all subcontractors, <br />laborers, materialmen and suppliers except as listed on Attachment A, below; (3) title of all Work, <br />materials and equipment incorporated in said Work or otherwise listed in or covered by this <br />Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security <br />interests and encumbrances (except such as are covered by a Bond acceptable to OWNER <br />indemnifying OWNER against any such Lien, security interest or encumbrance); (4) all Work <br />covered by this Application for Payment is in accordance with the Contract Documents and not <br />defective; and (5) If this Periodic Estimate is for a Final Payment to project or improvement, I further <br />certify that all persons doing work upon or furnishing materials or supplies for this project or <br />improvement under this foregoing contract have been paid in full, and that all taxes imposed by <br />Chapter 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and <br />discharged, and that I have no claims against the OWNER. <br />Attached to or submitted with this form are: <br />1. Signed release of lien forms (partial or final as applicable) from all subcontractors, laborers, <br />materialmen and suppliers except as listed on Attachment A, together with an explanation as <br />to why any release of lien form is not included; <br />00622 - Contractor's Application for Payment - 03-10 rev <br />00622-1 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1806 Indian River Blvd and Grand Harbor Blvd -Mast Arms\1-Admin\Bid DocumentsWaster Contract Documents Re-Bid\00622 <br />- Contractors Application for Payment - 03-10 rev.doc Rev. 05/01 <br />