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40 <br />i <br />PROJECT NO: <br />PROJECT: <br />CONTRACTOR NAMEIADDRESS: <br />May 25, 1999 <br />INDIAN RIVER COUNTY, FLORIDA <br />APPLICATION FOR PAYMENT NO. <br />ACCOUNT NO: <br />APPLICATION DATE: _FOR PERIOD ENDING: <br />STATEMENT OF WORK <br />Original Contract Price S Materials Stored S <br />Attach detailed schedule and paid invoices) <br />Net Change Orders S <br />tt C'^' °^`•w Total Work/Material to Date <br />Work to Date: Less 10 Retainage <br />Under Original Contract S Sub Total <br />Under Change Order S Less Prior Pavments <br />Percent of Work completed to date a <br />BALANCE DUE THIS PAYMENT S <br />Contraclps Crti(icalion <br />The urderrigned CONTRACTOR hereby des that all items and amounts on the face of this application for payment are correct; that all work has been performed ad/or <br />materials supplied in full accordance with the temps and conditions of the contract. <br />The udarzvcd0011`1Ct")R hudry swear under panaWyofpclury that (1) all previous progress payments receival from the OWNER on account of work performed under <br />the ou tract referenced to stove have been applied by the urdemigpW to discharge in full all obligations of the undersi®ned incurred in connection with work covered by prior <br />Appboatipv fir Payment wrier said contract, being Applications for Payment numbered I through inclusive; and (2) all matmals and equipment incorporated <br />in said project or otherwise listed in m covered by this Application fa Payment are free and clear ofall liens, claims, security intermix and encumbrances. <br />Dated '19 <br />BY: <br />Contractor) niv;sipn eI <br />Name/fille) ---—Public Works Director Approval <br />COUNTY OF INDIAN RIVER <br />STATE OF FLORIDA <br />Before me this day of , 19__, personally appeared <br />known to me, who being duly swom. deposes and sayvthat (s) he is the of the CONTRACTOR above mentioned; that (s)hc executed the above <br />AtOcetim f r Pay7,vY end Statement on behalf of said CONTRACTOR; and that all of the stalanenta contained herein arc true, correct and complete. <br />Notary Public <br />My Cotmnission Expires <br />PA -1