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SECTION 00622 - Contractor's Application for Payment <br />4TH STREET CULVERT REPLACEMENT AT 90TH AVENUE <br />Application for Payment No. <br />For Work Accomplished through the period of through <br />To: Indian River County (OWNER) <br />From: (CONTRACTOR) <br />Project No.: IRC -2022 <br />Bid No.: 2021045 <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 />5% 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 and <br />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 Application <br />for Payment will pass to OWNER at time of payment free and clear of all Liens, security interests and <br />encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER <br />against any such Lien, security interest or encumbrance); (4) all Work covered by this Application for <br />Payment is in accordance with the Contract Documents and not defective; and (5) If this Periodic <br />Estimate is for a Final Payment to project or improvement, I further certify that all persons doing work <br />upon or furnishing materials or supplies for this project or improvement under this foregoing contract <br />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 discharged, <br />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 />Contractor's Application for Partial Payment - 06-09 rev - 00622 - 1 <br />F:\PublicWorks\ENGINEERING DIVISION PROJECTS\2022 4th St Culvert Replacement at 90th Ave\1-Admin\Bids\Bid Documents\DIV 0 3 Contract Forms - 20201118.docx <br />