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4W <br />CI <br />INDIAN RIVER COUNTY, FLORIDA <br />✓ APPLICATION FOR PAYMENT NO. &I$ cin" <br />PROJECT NO.9625B 4N - <br />PROJECT: DONALD h"CDOI`rALD PARK LMPROVEMENTS rREJFD <br />CONTRACTOR NAME/ADDRESS: Summ t ConshructionManagement. fVero Beach. Florida32966APPLICATION DATE: Janua[y 3.2000 FOR PERIOD ENDING: Jawng= 3.2000m t)L� <br />Original Contract Price <br />Net Change Orders <br />Current Contract Price <br />Work to Date: <br />Under Orig. Contract <br />Under Change Order <br />Percent of Work comp.to date: <br />STATEMENT OF WORK <br />$252,717.00 <br />Materials Stored <br />(Attached detailed schedule) <br />+$1,469.00 <br />t� S <br />Total Work/Material to Date <br />$254,186.00 <br />67 <br />Less 1W. Retainage <br />ZSF 7/7 OD <br />Sub Total <br />$23 .00 <br />f <br />that (s) he is the <br />of the CONTRACTOR above mentioned; that (s)he executed the <br />Less Prior Payments <br />$1,469.00 <br />Payment �o <br />100% <br />�E <br />$254,186.00 <br />42S4+8•:6e— O <br />su�:�,2Sy /8Gr ofl <br />BALANCE DUE THIS PAYMENT $25,418.60 ✓ <br />RETAINAGE <br />CONTRACTORS CFRTIFICATION <br />The undersigned CONTRACTOR hereby certifies that all items and amounts on the face of this application for payment are correct; <br />that all work has been performed and/or materials supplied in full accordance with the terms and conditions of the contract. <br />The undersigned CONTRACTOR hereby swears under penalty that (1) all previous progress payments received from OWNER on <br />account of work performed under the contract referenced to above have been applied by the undersigned to discharge in full all <br />obligations of the undersigned incurred in connection with work covered by prior Applications for t under said contract 'ng <br />Applications for Payment numbered 1 through 5 inclusive; and (2) all materials and equipment i o711. <br />d in said prof 0 <br />otherwise listed in or covered by this Application for Payment are free and clear of all liens, cl msty interes encumbrances. //�i I <br />Dated L�z \. 19 To� <br />,� /A�Architect aU <br />Summit Construction Management. Inc <br />(Contractor) <br />Division Approval <br />t� S <br />By: <br />(Name/Title) <br />Public Works Director <br />COUNTY OF INDIAN RIVER <br />STATE OF FLORIIZA <br />Beforeme this t.10 day of" C <br />19_1, personally appeared <br />— known to me, who being duly swom, deposes and says <br />f <br />that (s) he is the <br />of the CONTRACTOR above mentioned; that (s)he executed the <br />ab— Applica,ion f_r Payment and Stalc.• n M f -'d PftTl'fP A!`TnP end Stt_'T�/lll,pf tl,r crate vents rnrttair�vt herr in �.r <br />r SUT1 �fEsG'6i.Yity <br />true correct and complete %�. <br />• r- Approved for <br />VNI <br />Payment �o <br />FIT --q OWAYY PV6UC <br />�E <br />DATZFebruary 1 , 2000 Dat 4 <br />6gomry .My 111INE3A NEINpgp <br />COMMISSION CC Arg+qc <br />�" 11 45 4f1a�resPXi-:Fi <br />i,- —=�...7..2 <br />�ACCt <br />^ <br />�Asativur,otaryAbrct►,os,,,,y,s . <br /><���'=`�T,cEcy fr�r g. <br />Adams i -man <br />