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i <br />4D <br />i <br />INDIAN RIVER COUNTY, FLORIDA <br />APPLICATION FOR PAYMENT NO. SB <br />PROJECT NO.9625k <br />PROJECT:DAtE �'J►A"t3R0�` ASK I i'I�iZflVF!VIEnu <br />CONTRACTOR NAME/ADDRESS: ►Iy " ^'' " u",wr„„•nr In 1944 587[1 �e - <br />V:ro Beach jpdda 32966 <br />0 <br />APPLICATION DATE: uar,Y 3 2044! FOR PERIOD ENDING: San 3.2000 <br />Et+�;ryt*_RIP�6 <br />4NC5ltl"� <br />Original Contract Price <br />Net Change Orders <br />Current Contract Price <br />Work fo Date: <br />Under (rig. Contract <br />Under Change Order <br />percent of Work comp.to dale:. <br />STATEMENT OF WORK <br />5258,349,00 Materials Stored <br />(Attachtd delailcd schedule) <br />5233.58 <br />Total WorklMaicrial to Date <br />S <br />$258,582.58 <br />$258,582.58 <br />Less 10°!o Retainage $0.00 <br />Sub Total $258,582.58 <br />5258,349.00 <br />Less Prior l'avnrcnls $230,758.56 +r <br />5233.58 its" <br />100% <br />BALANCE DUE THIS PAYMENT $27,824.02 <br />RETAINAGE <br />5,nlg �roR • ' Il�t •nTloN <br />The undersigned CONT RAC TOR hereby scrnfies that all items and amounts on the !'ace of this application far paymcnt are corium <br />that all work hus been performcd andlor materinis supplied in full accordance with the Icons and conditions 01'111C contract. <br />The undersigned ('ONTRACTOR. hereby swears under penally that (1) all prcvInus progress payments received from OWN LIt on <br />account of work perlormed under the conlraci rcfcrenccd to above have been applied by the undersignedto d,sch cin full al <br />obligations of d$c undersigned incurred in eonnectian will$ work coveted by prior Applications lar Payment under aid cunlracL h ing <br />Applications for Payment numbered I Through 5 inclusive; and t2) atl materials and equipmun[ incarporatVd ,n s; d project or + / <br />ollicrwisc luted in or covcrcd by this Application for 1'aynwnl arc free and Vicar of all liens, claims, security t Icsts and /!/f <br />en"mbrances. <br />Datcd---by,�• t`3 J !� <br />Architcc `— <br />`Sumllttt ConrstttlClLBI1Rn..ocment, Inc. <br />(Contractor) <br />(Namerrit}c) <br />COUNTY OF INDIAN R[VERC- <br />I <br />► A <br />Division Approval <br />Wuhlic Works Dircetor <br />STATG Ur FLOR Tk y <br />Before ore this L � Jay of _1 to .personally appeared <br />r <br />�i. 0 me. w]ui Le,ng duty sworn, dcpes¢s and says <br />'`:nt (s) he is the s a�-. of [lee CONTRA” rryit abgve mentioncd; Thal (s)hc executed the <br />n1Mvg Application for Pay,r+nn. . r'fir�`r'.!` n : *n -o s'n 1^f TIt,Af"t' S;., a+rn thyCatf f Thr statenvnts ea nlmncd 1,erc in are <br />true,correclandcomplete. r38rd O n Y (5ff1M1r:Pil�i+ T <br />,Approved for Payment r <br />grr+AN g1YER f7AJttSY KB IC W"'s <br />x — <br />`nH'F Ul--jL February 1, 2000 [Jetta ! Notary Publ <br />.vw <br />_ p h . Al3NES&HELI}OSKI <br />{3l Y:C _ �' 4� I ABY COMMISSION 1 CC 80156 <br />Y�tY My L"unnni 1 i . EXPIRES: July?a, ^20 <br />4 9 �� r�,�Ts • Banded IM 1"ry PuW tMnMwH,rn <br />Fran g Chairman <br />