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1SECTION 00622 - Contractor's Application for Payment <br />Sector 5 Beach and Dune Restoration Project <br />Application for Payment No. 1923-5 <br />For Work Accomplished through the period of 3/01/20 through 5/25/20 <br />To: Indian River County (OWNER) <br />From: RIO-BAK CORPORATION(CONTRACTOR) <br />Bid No.: 2019066 <br />Project No.: IRC -1923 <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 />$4,511,712.00 <br />$1,459,908.94 <br />$5,971,620.94 <br />$5,971,620.94 <br />93% of completed Work: <br />0% of retainage: <br />Total Retainage: �0 <br />6. Total completed and stored to date less retainage (4 minus 5): $5,971,620.94 <br />7. Less previous Application for Payments: $5,437,454.06 <br />8. DUE THIS APPLICATION (6 MINUS 7): $534,166.88 <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, 1 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 />IRC-1923_PAYAPP 5 FINAL FINAI.doc <br />00622 - 1 <br />F:.Active Projects\VERO BEACH RESTOREIBILLINGURC-1923_PAYAPP 5 FINAL FINAL.doc Rev. 05101 <br />