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Cil INDIAN RIVER COUNTY, FLORIDA APPLICATION FOR PAYMENT NO.— PROJECT NO: -267.9A ACCOUNT PROJECT: SU()QTING RANVGE - SITEWORK CONTRACTOR NAMElADDRES& APPLICATION DATE: FOR PERIOD ENDING CW �{,¢��" rtk'fiCati6�1 The undersigned CONTRACTOR hereby certifies that all items and amounts on the face of this application fur payment are correct; that all work has been performed and/or materials supplied in fill accordance with the terms and conditions of the contract. 'clue undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous progress payments received from the OWNER on account of work performed under the contract referred to above have been applied by the undersigned to discharge in fill all obligations of tine undersiipued incurred in connection with work covered by prior Applications for Payment under said contract, being Applications for Payment numbered I through biclusive; and (2) all materials and equipment incorporated in said project or otherwise listed in or covered by tliis Application for Payment are free and clear of all Piens, claims, security interests and encumbrances. Dated 11999 (Contractor) BY: (NainelTitle) COUNTY OF INDIAN RIVER sTATI"OF FLORIDA Before me this day of 1999, personally appeared known to me, who being duly sworn, deposes and says that (s)hc is the Of the CONTRACTOR above mentions that Whe executed die above Application for Payment and statement on behalf of said CONTRACTOR; and that all of tate statements contained hereto are true, correct and complete. Notary Public My Commission Expires:_ APPLICATION FOR PAYH9NT AP - 1 STATEMENT OF WORK Original Contract Price Materials Stored $� NO Change Orders S-- (Attadi details schedule and paid invoices) Current Contract Price $ Total WordlMatcrials to Date $_ Work to Date: Less 10% Retainage $ Under Original Contract $ Sub Total $ _ Under Change Order S____ Less Prior Payments Percent of Work Completed to Da rc % BALANCE DILE THIS PAYMENT S CW �{,¢��" rtk'fiCati6�1 The undersigned CONTRACTOR hereby certifies that all items and amounts on the face of this application fur payment are correct; that all work has been performed and/or materials supplied in fill accordance with the terms and conditions of the contract. 'clue undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous progress payments received from the OWNER on account of work performed under the contract referred to above have been applied by the undersigned to discharge in fill all obligations of tine undersiipued incurred in connection with work covered by prior Applications for Payment under said contract, being Applications for Payment numbered I through biclusive; and (2) all materials and equipment incorporated in said project or otherwise listed in or covered by tliis Application for Payment are free and clear of all Piens, claims, security interests and encumbrances. Dated 11999 (Contractor) BY: (NainelTitle) COUNTY OF INDIAN RIVER sTATI"OF FLORIDA Before me this day of 1999, personally appeared known to me, who being duly sworn, deposes and says that (s)hc is the Of the CONTRACTOR above mentions that Whe executed die above Application for Payment and statement on behalf of said CONTRACTOR; and that all of tate statements contained hereto are true, correct and complete. Notary Public My Commission Expires:_ APPLICATION FOR PAYH9NT AP - 1