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CONTRACTOR NAMEJADDRESS: <br />INDIAN RIVER COUNTY. FLORIDA <br />AMICATION FOR PAYMENT NO. <br />APPI.JCATION DATE: FOR PERIOD ENDWO: <br />Original Contract Price S <br />Net Chale Orders S <br />Crwresd Contract Price S <br />Work to Date: <br />Under Original Conlract S <br />Under Change (rder S <br />Percent of W ork completed to date 95 <br />STATP.MENTOP WORK <br />Materials Stored S <br />(Attach detailed schedule and ,paid invoices) <br />Total WorkAl terial to Date S <br />Lass 101 Retainage S <br />Sub Total S <br />Less Prior Payments $ <br />11Tx�3'liCa]I+� EIFd ai[!I I E��iS' '��lit Y <br />May 25, 1999 <br />c4muaGt.w CC&Nfiw ou <br />The undesig ad COMRACTOR hereby mCfirx host all ium aM amnrmta m the fax of this tMlicaum for payment we erred: that all work has been Nr0wa sudor <br />mw=als supplied in fnl l awordsnce with the terms and conditions oftho czot am <br />The undxggxd 001MACM 6lby swims uwW pnWt, ofpcgwy ihat(1) al: jwe m punas paymenu roccived frau Ole OWNER apt@&�t ofWIXi perfamaedumkf <br />the extras referenced to by. have been .ppl!cd by wWrfatgned to dtrchu ge in full all nhli tLl of the wadmiped irwvned im conrte io with work owrad by Prior <br />P.lpixwi—for Payoaera carder said eomuwi; being Appliwioru for Payaa m nwnbemd I through vaelmiit, .d (2) a11 matniels ad eq.gwwru InonrporatW <br />N rad project or otherwise luted in am ,—d by rias Applieatton fa Payor t arc fim rad clw ofalI Lem, elairm, senmty interests and encwnbrances. <br />Date[ .19 <br />(C -trader) Division Approval <br />BY: <br />(Nantdfilla) Public Works Diroclor Appaoval Y <br />COUNTY OF INDIAN RIVER <br />STATE OF FLORIDA <br />Ekfom me this day of_ , 19_ persoacally appeared <br />kftown to mo, who lxing duly sworn, delwscs and says <br />that (s)bc is the of the CONTRACTOR above mentioned: that (s)he executed Ute above <br />APplisation farPaynvat and Statement on behalfofsaid CONTRACTOR; std that all ofthe atatetumits contained herein rue true, correct and complete. <br />Notary Public <br />My Connnission Expires <br />PA -1 <br />