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U 10-%5V-00 H:06AM FR064- I!a Lj I^II ItIV "A %-%j Ulal !, ri utusiA APPLICATION FOR PAYMENT NO— .WI- PROJECT NO:_ --q332 AccOLM NO T-910 P.02/05 F-773 IPROJECT:,'CR SI0 & l Lii76RSGT.i�-N IM ROU MENS._, TS_.. IC ONTRACTORNAMFJADDRESS: -RANGER CONSTRUCTION INDUSTRIES INC. 145 GL ES CUT OFF ROAD PLICATION DATE: -1 L1QJAc FOR PERIOD ENDING–jQ/_8.1/.Qg_____ _____ STATEMENT OF WORT: Original Contract Price $ '461,066.65 Materials Stored ' S -Q Net Change Orders $ 7404.82 (Attach detailed schedule and paid invoices) Current Contract Price e __ Total Word/Materials to Date $ 509,471.47 Fork to Date; Less 10% Retainage S 0 Under Original Contract Under Change Order 5 4f21.4S3 82 Sub Total Less Prior Payments S_509,47 1, 47 S_399 , acj` '� 1c1, 2 1 'ercent of Work Completed to Date—'/- ate%BALANCE BALANCEDUE THIS PAYMENT S_ 109_:704.20_ {��. . C tom. rap . ctors_ e E19Ati n The undersigned CONTRACTOR hereby certifies that all items and amounts on the face of this application for payment are correct; that all work has bun performed and/or materials supplied in Rill accordance with the terms and conditions of the contract. The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous progress payments received from the OWNER on account of work perfonned under the contract referred to above have been applied by the undersigned to discharge in ftlll all obligations of the undersigned incurred in connection with work covered by prior Applications for Payment under said contract, being Applications for Payment numbered I through __ inclusive; and (2) all materials and equipment incorporated in said project or other% ise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances. Dated NOVEMBER 10 1999 WGER CONSTRUCTION INDUSTRIES, INC. (Contractor) e/T le) VICE PRESIDENT COUMY OF INDIAN RIVER STATE OF FLORIDA Before nne thisl TH day of NOVEMBER _`__, 19 99 , personally nppexed WGV l G. CORREA _ , known to me, y,ho beinS duly swom, deposes and saps that (s)he is theVlt C pf(p$�pEtIT of the CONTRACTOR above mentions: that ON executed the above Application for Payment and statement on behalf of said CONTRACTOR; and that alt i`II ements contained herein are tntc, correct and complete. Board g9,County'Qgmntission Nota ublic Approved for Payment My Commission Expil to At EA Maio a area ', MY Cantu &P. IVM2001 I No IC No. cc 705GT0 t1 -v- rtl fiat0 � nl7asm�li Wawn I IUMw tr). FOR PRYI MNT AP - 1 Ketxtijtt M I —ch T Chairman