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i <br />11 <br />INDIAN RIVER COUNTY, FLORIDA AUG j I ,-i99 L <br />APPLICATION FOR PAYMENT NO.35— <br />DEPT. , <br />PROJECT NO:9623 ACCOUNT NO:315.-'10-572-068.09 <br />PROJECT: WABASSO CAUSEWAY PARK BEAUTIFICATION PROJECT <br />CONTRACTOR NAME/ADDRESS: �iYL'\�i �Y��\� C� t7f �7Y�^� tom✓) _ <br />APPLICATION DATE: I ►o I�� _ FOR PERIOD ENDING_(ollrt�( <br />STATEMENT OF WORK <br />Original Contrail Price $ c�lQ3. Materials StId $_ — 0 — <br />Net Change Orders $ �;2, 4QQ (Attach detailed schedule and paid invoices) <br />Current Contract Price $ • ` ZVotal Word/Materials to Date $oi(o5,_801,ga <br />Work to Date: Less 10% Retainage $ <br />Under Original Contract $ Sub Total $'2iq �•9D <br />Under Change Order $�ICfE • (oa. Less Prior Payments $ --:):E!J9 , Q, +� <br />Percent of Work Completed to Date 4/0 <br />BALANCE DUE THIS PAYMENT G <br />Contractors Certification <br />The undersigned CONTRACTOR hereby certifies that all items and amounts on the face of this application for <br />payment are correct; that all work has been performed and/or matenals supplied in full accordance with the terms <br />and conditions of the contract. <br />The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous progress payments <br />received from the OWNER on account of work performed under the contract referred to above have been applied <br />by the undersigned to discharge in full all obligations of the undersigned incurred in connection with work covered <br />by prior Applications for Payment under said contract, being Applications for Payment numbered 1 through -� <br />- inclusive; and (2) all materials and equipment incorporated in said project or otherwise listed in or covered by this <br />Application for Payment are free and clear of all liens, claims. security interests and encumbrances <br />Dated 2 �t� 1pfi R)<AV- '�C�Y�z' c- <br />ni01AN IVER COUNTY PUWI wOWO <br />BY:_��<;%J✓�! APPROVED GATE <br />(Nam le) OrRt; �� `' `' <br />DIV. HEAD j / <br />P.O. • <br />i G,.:_,� , 51 <br />=S'E 19!1�1 personally appeared <br />vho being duly sworn, deposes and says that (so Is the <br />FACTOR above mentions, that (s&executed the above <br />nt on behalf of said CONTRACT bar o <br />tthal+ of-�►i® <br />corr t d complete aunty Commission <br />Apprtivery for Pavnrent <br />Notary Public --------_---- -- ----- <br />My Commission Expires,2 �,�1 9 D_�te <br />A:'NI.Ii ATION F09 PAYMENT <br />Ar I <br />