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£ abed 888L699ZLL dZT : 60 900ZJST UEZ 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 dear 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 th a e no claims against the OWNER. Dated2 - i.l= C� �OAITRA T - R) State of �02(Cl�/ County of „r J � Subscribed and s n to before me thiS+'VA! 4 CAROL T. BESANCON day of a-�_�6�_ 07� O y;1 �' MV COMMISSION k DD 452154 Notary Public �A,Ppz '-7`^ gr),�Cyy''y7 Zrof jt& aPIRES: September 27, 2009 co My Commission expires: taN®iApY s6nmw DIMWIT[DIMWIT[ /woo. . NOTICE OF NON-PAYMENT if one or more Notice of Non-Payment" or Notice to Owner" is received by the OWNER, no further payments will be approved until non- payment(s) have been satisfied and a "Lien Waiver" for each "Notice " has been submitted to the OWNER. Upon request, CONTRACTOR shall furnish acceptable evidence that all such claims have been satisfied. The CONTRACTOR may, with consent of Surety and indemnification of the OWNER against any claims, receive payment for work for which there is an outstanding Notice of Non-Payment" or `Notice to Owner. " CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLE) : I certify that 1 have checked and verify the above and foregoing Periodic Estimate for Partial Payment; that to the best of my knowledge and belief it is a true and correct statement of the work performed and/or material supplied by the Contractor. Dated (ARCHITECT / ENGINEER) SIGNATURE CERTIFICATION OF ENGINEER / INSPECTOR- I have checked the estimate against the Contractors Schedule of Amounts for Contract Payments and the notes and reports of my inspections of the project. It is my opinion that this statement of work performed and/or materials supplied is accurate, that the Contractor is Contractors Application for Payment-Oosm 00622 - 2 'Al It'll irv _ cs.a. nva«.., ..�oo.... ....... ...__. .. ._..__..-__.._.._.� ._u:�._ ._. .._. ___. ......_ . £'d 888L499ZLL ONIlOV2Jil 0 3SOLi MiOINIl d8L £0 g0 91, qa3