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M <br />Im <br />Dated <br />By: <br />State of <br />County of <br />Subscribed and sworn to before me this <br />day of <br />Notary Public <br />My Commission expires: <br />(CONTRACTOR) <br />NOTICE OF NON-PAYMENT. If one or more "Notice of Non -Payment" or "Notice to <br />Owner" is received by the OWNER, no further payments will be approved until non- <br />payments) have been satisfied and a "Lien Waiver" for each "Notice" has been submitted <br />to the OWNER. Upon request, CONTRACTOR shall furnish acceptable evidence that all <br />such claims have been satisfied. The CONTRACTOR may, with consent of Surety and <br />indemnification of the OWNER against any claims, receive payment for work for which there <br />is an outstanding "Notice of Non -Payment" or "Notice to Owner." <br />CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLEZ <br />I certify that I have checked and verify the above and foregoing Periodic Estimate for Partial <br />Payment; that to the best of my knowledge and belief it is a true and correct statement of the work <br />performed and/or material supplied by the Contractor. <br />Dated <br />(ARCHITECT/ ENGINEER) SIGNATURE <br />I have checked the estimate against the Contractor's Schedule of Amounts for ontrac <br />Payments and the notes and reports of my inspections of the project. It is my opinion that this <br />statement of work performed and/or materials supplied is accurate, that the Contractor is observing <br />the requirements of the Contract, and that the Contractor should be paid the amount requested <br />above. <br />Dated <br />Accompanying Documentation: <br />(ARCHITECT / ENGINEER) SIGNATURE <br />[The Remainder of Page Intentional Left Blank <br />00622 - Contractor's Application for Payment 2006041 <br />00622-2 <br />,., F:\Public Works\Capital Projects\Oslo Road Lateral J\BID DOCUMENTS 2006041\00622 -Contractor's Application for Payment 2006041.doc Rev. 05/01 <br />