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Page 4 of 5 <br />CERTIFICATION OF ENGINEER: <br />I 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 <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 />F:\Public Works\ENGINEERING DIVISION PROJECTS \1317 -85th St Milling91st Ave to 101st Ave1Admin\bid documents Master Contract Documents\00622 - Contractors Application <br />for Payment - 03-10 rev.doc Rev. 05/01 <br />