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'rl - II ' <br /> c�nwwar ►aahnlrs� �r ,► _ 790 N . E . 48" Street , Pompano Beach , Florida 33064 <br /> Application for Payment No . 1 . FWAL <br /> For Work Accomplished through the period of Mal/ 171h through June 17th 2005 <br /> To : Indian River County (OWNER) <br /> From : The Danella Companies , Inc. , Utilities Labor Contractor <br /> Project Name : Chesser' s Gap Force Main Bypass along CR 512 <br /> COUNTY WIP NO . : 471 . 26836-044699 <br /> ENGINEER OF RECORD : Gordon E . Sparks , P . E . . <br /> 1 . Original Contract Price : $ 14 , 148 , 36 <br /> 2 . Net change by Change Orders and Written Amendments ( + or - ) : ($2 , 872 . 60 ) <br /> 3 . Current Contract Price ( 1 plus 2 ) : $ 17 , 020 . 96 <br /> 4 . Total completed and stored to date $ 17 , 202 , 96 <br /> 5 . Retainage ( per Agreement) : <br /> 0 % of completed Work : N/A <br /> 0 % of stored material : N/A <br /> Total Retainage : N/A <br /> 6 . Total completed and stored to date less retainage (4 minus 5 ) : $ 172020 . 96 <br /> 7 . Less previous Application for Payments : $0 . 00 <br /> 8 . DUE THIS APPLICATION (6 MINUS 7) : 17 020 . 96 <br /> (°') If applicable, an Itemized list of labor and/or materials furnished and installed I s attached. <br /> CONTRACTOR'S CERTIFICATION : <br /> The undersigned CONTRACTOR certifies that ( 1 ) all previous progress payments received from <br /> OWNER on account of Work done under the Contract referred to above have been applied on <br /> account to discharge CONTRACTOR' s legitimate obligations incurred in connection with Work <br /> covered by prior Applications for Payment numbered 1 through 2 inclusive ; (2 ) title of all Work , <br /> materials and equipment incorporated in said Work or otherwise listed in or covered by this <br /> Application for Payment will pass to OWNER at time of payment free and clear of all Liens , security <br /> interests and encumbrances (except such as are covered by a Bond acceptable to OWNER <br /> indemnifying OWNER against any such Lien , security interest or encumbrance ) ; (3 ) all Work <br /> covered by this Application for Payment is in accordance with the Contract Documents and not <br /> defective and (4 ) If this Periodic Estimate is for a Final payment to project or improvement , I further <br /> certify that all persons doing work upon or furnishing materials or supplies for this project <br /> or <br /> improvement under this foregoing contract have been paid in full , and that all taxes imposed by No . <br /> 212 Florida Statutes , ( Sales and Use Tax Act , as Amended ) have been paid and discharged , and <br /> that I have no claims against the OWNER . <br /> Dated <br /> ( NTRA <br /> By: 1 <br /> r , <br /> State of <br /> County of <br /> Subscribed and sworn to before m s .�0 .7H <br /> day of , / 2vc S NICHOLAS J . FIDUCCIA <br /> Notary Public NOTARY PUBLIC - STATE OFFIARIDA <br /> COMMISSION N DD136M <br /> My Commission expires : SONDE PES M <br /> THRRU 14 &WINW-NOTARYI <br /> Page 1 of 2 <br /> Z:Uob Folders\Indian River County\Annual Contract\Chesser's Gap\Npplication for Payment - Chesser's Gap.doc Rev. 07/01 <br />