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APPLICATION FOR PAYMENT NO. <br />15F <br />To: Indian River County Utilities (OWNER) <br />From: TLC Diversified, Inc. (CONTRACTOR) <br />Contract: <br />PROJECT: Roseland Elevated Storage Tank and Pump Station <br />OWNER's Contract No. 2019-067 <br />For Work accomplished through the date of: 08/31/2022 <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 />0.00% % of Completed Work: $0.00 <br />0.00% % of Stored Materials $0.00 <br />$1,691,200.00 ?fid `' <br />-$27,697.74 ''� 00- <br />$1,663,502.26.11, <br />$1,663,502.26 .A <br />Total Retainage: $0.00 <br />6. Total completed and stored to date less retainage (4 minus 5): $1,663,502.26 <br />7. Less previous Apllications for Payments: $1,580,327.15 <br />8. DUE THIS APPLICATION (6 MINUS 7): $83,175.11 <br />Accompanying Documentation: See attached Sheets. <br />CONTRACTOR'S Certification <br />The undersigned CONTRACTOR certifies that (1) title to all Work, materials and equipment incorporated in said Work or <br />otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens, <br />security interests and encumbrances; (2) all Work covered by this Application for Payment is accordance with the Contract <br />Documents and not defective; and (3) the labor and materials listed on this Application for Payment have been used in the <br />construction of this Work and payment received from the last progress payment has been used to make payments to all <br />subcontractors, laborers, materialmen and suppliers except as listed below: NONE <br />Dated 08/30 2022 TLC Diversified, Inc. <br />ONTRACTOR <br />By: <br />Mark Selph, Operation anager <br />State of Florida <br />County of Manatee <br />Subcribed and sworn to before me this 30th <br />day of August 2022 <br />C <br />CNLfft. <br />4j <br />uU;MN McoovErr <br />Notary publk <br />— State Florida <br />Canml HH2O2763 <br />19 Erp1res11n9/=S <br />Not ubllc <br />My Commision expires: 11129/2025 <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated g _ 9, 7,2 - <br />ENGINEER iENGINEER <br />By: <br />EJCDC No. C -700-E (2002 Edition) <br />Prepared by the Engineers Joint Contract Documents Committee and endorsed by The Associated General Contractors of America and the Construction <br />Specification Institute. <br />00800-26 <br />Printed : 8/30/2022 Page 1 of 8 TLC Job 19-1501 <br />