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IND <br />INN <br />IMP <br />wr <br />Page 4 of 5 <br />CERTIFICATION OF ENGINEER: <br />certify that I have reviewed the above and foregoing Periodic Estimate for Partial <br />Payment; that to the best of my knowledge and belief it appears to be a reasonably <br />accurate statement of the work performed and/or material supplied by the Contractor. I am <br />not certifying as to whether or not the Contractor has paid all subcontractors, laborers, <br />materialmen and suppliers because I am not in a position to accurately determine that <br />issue. <br />Dated <br />SIGNATURE <br />CERTIFICATION OF INSPECTOR: <br />I have checked the estimate against the Contractor's Schedule of Amounts for Contract <br />Payments and the notes and reports of my inspections of the project. To the best of my <br />knowledge, this statement of work performed and/or materials supplied appears to be <br />reasonably accurate, that the Contractor appears to be observing the requirements of the <br />Contract with respect to construction, and that the Contractor should be paid the amount <br />requested above, unless otherwise noted by me. I am not certifying as to whether or not <br />the Contractor has paid all subcontractors, laborers, materialmen and suppliers because i <br />am not in a position to accurately determine that issue. <br />Dated <br />SIGNATURE <br />**************************************************************************************************** <br />[The Remainder of This Page Was Left Blank Intentionally] <br />00622 - Contractor's Application for Payment - 03-10 rev <br />00622 - 4 <br />PA��'chr_ Wok_vENGINEEP.ING DIVISION PROJEC`Sy022. _01h A..anc a I .e,seu tr:,ove ie tAJ,rn^Vbio ❑Deur _n1._ 1 s:., Conn Docu menu'00E22 -:;or. <br />rca co; Eec .. <br />