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Page 4 of 5 <br />CERTIFICATION OF ENGINEER: <br />I certify that I 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 issue. <br />Dated <br />SIGNATURE <br />CERTIFICATION OF INSPECTOR: <br />I 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 of the <br />Contract with respect to construction, and that the Contractor should be paid the amount <br />requested above, unless otherwise noted by me. 1 am not certifying as to whether or not the <br />Contractor has paid all subcontractors, laborers, materialmen and suppliers because I am <br />not in a position to accurately determine that issue. <br />Dated <br />SIGNATURE <br />[The Remainder of This Page Was Left Blank Intentionally] <br />Page 5 of 5 <br />00622 - Contractor's Application for Payment - 03-10 rev <br />00622-4 <br />F:\PublicWoFks\ENGINEERING DIVISION PROJECTS\1806 Indian River Blvd and Grand Harbor Blvd -Mast Arms\1-Admin\Bid Documents\Master Contract Documents Re-Bid\00622 <br />- Contractors Application for Payment - 03-10 rev.doc Rev. 05/01 <br />