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SECTION 00622 - Contractor's Application for Payment.doc Application for Payment No. For Work Accomplished through the period of through To: Indian River County (OWNER) From: (CONTRACTOR) Contract: Project: Oslo Road (CR606)/ Lateral `J' Canal Bridge Replacement. OWNER's Contract No, 9705B, ENGINEER Indian River County Public Works Department. ENGINEER's CONSULTANT. Kimley-Horn and Associates, Inc. 1. Original Contract Price: $ 2. Net change by Change Orders and Written Amendments (+ or -): $ 3. Current Contract Price (1 plus 2): $ 4. 4.a 4.b 4.c Total Work to date: Percentage of Work completed to date: Total Work completed to date: $ Total equipment and material stored to date: $ (1) 4.d Total Work completed and stored to date: (4.b plus 4.c) $ 5. Retainage (per Agreement): 5.a 10% of completed Work (0.10 x 4.b): 5.b 20% of stored equipment and material (0.20 x 4.c): 5.c Total Retainage (5.a plus 5.b): $ 6. Total Work completed and stored to date less retainage (4.d minus 5.c): $ 7. Previous Payments: $ 8. AMOUNT DUE THIS APPLICATION (6 MINUS 7): $ (1) Attach detailed schedule and copies of all paid invoices. CONTRACTOR'S CERTIFICATION: UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that (1) the labor and materials listed on this request for payment have been used in the construction of this Work and payment received from the last request for payment has been used to make payments to all subcontractors, laborers, materialmen and suppliers except as listed below; (2) title of all Work, materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien, security interest or encumbrance); (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective and (4) If this Periodic Estimate is for a Final payment to project or improvement, I further certify that all persons doing work upon or furnishing materials or supplies for this project or improvement under this foregoing contract have been paid in full, and that all taxes imposed by Chapter 212 Florida Statutes, (Sales and Use Tax Act, as Amended) have been paid and discharged, and that I have no claims against the OWNER. 00622 - Contractor's Application for Payment 2006041 00622- 1 "" FAPublic Works\Capital Projects\Oslo Road Lateral J\BID DOCUMENTS 2006041\00622 - Contractor's Application for Payment 2006041.doc Rev. 05/01