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J <br />G <br />-v�- %2.54 56 <br />�,�� '9 <br />All(; 199,9 'N <br />D R <br />rEAIW <br />INDIAN RIVER COUNTY, FLORIDA ATEERIIW� -o <br />APPLICATION FOR PAYMENT NO. <br />PROJECT NO: 9723 ACCOUNT NO: <br />PROJECT% Oslo Road -St 27th AVe 'and Five Lane Widening of Oslo Road (DFI13208 ) <br />CONTRACTOR NAME/ADDRESS: nTCKFRSON FLORIDA- INC. <br />P.O. Drawer 719 Stuart Florida 34995 <br />APPLICATION DATEc 8/3/99 FOR PERIOD ENDING 7/30/99 <br />STATEMENT OF WORK <br />Original Contract Price $1.212.255.30 _ Materials Stored $ _ <br />Net Change orders ;i7.36,.00) (Attach detailed schedule and paid invoices) <br />Current Contrast Price ;1,204,£3f39.1 _ Total Work/Materials to Date ; 1,155.314.10 ✓/ <br />Work to Date: Lees 100 Retainage 57, $ 5 7,� X5.71 ✓ <br />Under Original contract ;1 -16 _IIg7. 91 Sub Total �Cr COG $L\, <br />Under Change Order S_f7,583.80 Less Prior Payments $ <br />Percent of Work Cc.npleted to date 96 <br />EALANCS DUE THIS PAYMENT <br />l <br />Ke <br />contractors certification <br />The undersigned CONTRACTOR hereby certifies that all items and amounts on the <br />face of this application for payment are correct; that all work has been <br />performed and/or materiaAA supplied in full accordance with the terms and <br />conditions of the contras . <br />The undersigned CQNTRACTOR hereby swears under penalty of perjury that (1) all <br />previous progress payments lreceived fSom the OWNER on account of work performed <br />underthe contract referred to above have been applied by the undersigned to <br />discharge in full All obligations of the undersigned incurred in connection with <br />work covered by prior Applications for Payment under said contract, being <br />Applications for Payment numbered 1 through 6 inclusive; and (2) all <br />materials and equipment incorporated in said pco)ect or otherwise listed in or <br />covPrpcs by thin Appli.cat;-on for Payment are tree and clear of all liens,_ claims, <br />security interests and encumbrances, t <br />f;fyN1 Rii}; <br />Y(A Ns 1 <br />Dated Atioust 3 1999 CKE.RSON FLORIDA INC. ImMIK.P5!) I DATE. <br />(Contractor) pEKCT(ff;�/Lj`'jf' <br />71, <br />(Name t1 ) IK) •__ .._..-J <br />COUNTY OF INDIAN RIVER Ted 11. Tyson, PresidenEAc . •Jt ���fy. It67%751 <br />STATE OF FLORIDA <br />Before me this 3rd day of Au(us t <br />, 1999 personally appeared <br />TTeedd �Jy�Qq_ <br />known to me, who being duly sworn, <br />_____ ____ <br />depo%ies and Hays that j(}(j(he s the <br />Prg.sident of the CONTRACTOR above <br />mentioned; that (a)he executed the above <br />Application for Psyment and statement <br />on behalf of naid CONTRACTOR; and that all <br />f, the statements contained herein are <br />true, correct and complete. <br />"r:' T•. Dawn T. Horne -Bounds <br />1 <br />/ <br />MYCOMMISSION I CC704419 1XGif'ES <br />; <br />tJ T vas yti's— <br />Ik?tRMXE wC <br />Notar- y Pub TIc <br />' �% <br />� <br />1;�/ w'_C D ,}(.�(/R� ' _ <br />My Commission Expires 11/19/99 <br />Board of County Commission <br />Approvod for Payment <br />eth R. MaCht Chairman <br />