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JUL 01 2015 <br /> APPLICATION FOR PAYMENT NO. 3 FINAL ii V <br /> To: Indian River County (OWNER) <br /> From: Tri-Sure Corporation (CONTRACTOR) <br /> Contract: IJCP4106 <br /> Project: 12"Transmission Water Main Extension on 107th Ave in Vero Lake Estates <br /> OWNER's Contract No.2015017 ENGINEER's Project No. <br /> For Work accomplished through the da of: 6/10111.. <br /> 1. Original Contract Price: $ 380,975.00 <br /> 2. Net change by Change Orders and Written Amendments(+or $ 0.00 <br /> 1 Current Contract Price(I plus 2): $ 380,975.00 <br /> 4. Total completed and stored to date $ 347,378.50 <br /> 5. Retainage(per Agreement): <br /> 0 %of completed Work: $ 347,378,50 <br /> Yo of retainage: <br /> Total Retainage: 0% $ 0.00 <br /> 6. Total completed and stored to date less retainage(4 minus 5): $ 347.378.50 <br /> 7. Less previous Application for Payments: s 327,549.08 <br /> 8. DUE THIS APPLICATION(6 MINUS 7): $ 19,829.42 <br /> Accompanying Documentation: 11-1 <br /> CONTRACTOR'S Certification: <br /> 912,- <br /> The undersigned CONTRACTOR certifies that(1)title to all Work,materials and equiom ZnQrporated in said <br /> Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free <br /> and clear of all Liens,security interests and encumbrances;(2)all Work covered by this Application for Payment is <br /> in accordance with the Contract Documents and not defective; and (3) the labor and materials listed on this <br /> Application for Payment have been used in the construction of this Work and payment received from the last <br /> progress payment has been used to make payments to all subcontractors,laborers,materialmen and suppliers <br /> except as listed below: <br /> Dated 6/30/15 f <br /> Tri-Surp&oration <br /> CONTRACTOR <br /> State of Florida Jason Chamars <br /> County of Folk <br /> Subscribed and sworn to bef PH <br /> 2 5me this 30th L"IE SHELFER <br /> day 91 Tune MY <br /> COMMSM#FF I2WO <br /> XPLRE6:Apo 16, 018 <br /> Notary Public <br /> My Commission expires: <br /> Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br /> Dated <br /> ENGINEER <br /> By: <br /> EJCDC No.C-700-E(2002 Edition) <br /> Prepared by the Engineers Joint Contract Documents Committee and endorsed by The Associated General Contractors of America and the Construction <br /> specification institute <br /> 00800-26 <br /> Attachment 1 64 <br />