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STATE OF FLORIDA <br /> COUNTY OF INDIAN RIVER <br /> Before me, a Notary Public, duly commissioned, qualified and acting , personally appeared <br /> AwDy rRe ?P , to me well known, who being by me first duly sworn upon oath , says that he is <br /> the attgrney-in-fact for the and that he has been authorized by <br /> ZfA ' .oto execute the foregoing bond on behalf of the CONTRACTOR named therein in favor of the <br /> iZ4ounty of Indian River, Florida . Subscribed and sworn to before me this /6 7"t day of <br /> /I7q-{w , 200 . <br /> Notary Public, State of Fl rid , a ¢ <br /> �? <br /> uuc8K <br /> ac <br /> F. <br /> �SSs <br /> E "mSMy COmmiss' n Expires: Qiiie wTrE <br /> MMMoDU1 <br /> 1IX9 <br /> pE'A :,^,an ^; panx Nne,Y 3n,:cwosn <br /> Accompanying Documentation : <br /> NOTICE OF NON-PAYMENT. If one or more "Notice of Non-Payment" or `Notice to Owner" is received by the <br /> OWNER, no further payments wit) be approved until non-payment(s) have been satisfied and a "Lien Waiver" <br /> for each "Notice " has been submitted to the OWNER. Upon request, CONTRACTOR shall furnish acceptable <br /> evidence that all 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 is an outstanding <br /> "Notice of Non-Payment" or "Notice to Owner. " <br /> CERTIFICATION OF ENGINEER: <br /> I certify that I have checked and verify the above and foregoing Periodic Estimate for Partial Payment; that <br /> to the best of my knowledge and belief it is a true and correct statement of the work performed and/or material <br /> supplied by the Contractor. <br /> Dated <br /> SIGNATURE <br /> CERTIFICATION OF ENGINEER I INSPECTOR: <br /> I have checked the estimate against the Contractor's Schedule of Amounts for Contract Payments and the <br /> notes and reports of my inspections of the project. It is my opinion that [his slalement of work performed <br /> and/or materials supplied is accurate, that the Contractor is observing the requirements of the Contract, and <br /> that the Contractor should be paid the amount requested above. <br /> Dated <br /> SIGNATURE <br /> 06622 - Contractor's Application for Pa>Ment 4-11#7 revised 5-16.doc <br /> 00022 - 2 <br /> S%0ccwrersCCNE RGRAAMf:CVRREA'r JOBS 'Z-0dIr.0W% RP/ER ANA" CGMr.-YrLtv2. - Cmfa ;'sAxe':.N.n 'a Fay.:znt 4-1147 reV40d >7A d= R--o. OS:G- <br />