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SECTION 00622 - CONTRACTOR' S APPLICATION FOR PAYMENT <br /> Application for Payment No , <br /> For Work Accomplished through the period of through <br /> ' To : Indian River CountyOWNER <br /> (OWNER) <br /> From : (CONTRACTOR) <br /> Contract: EAST GIFFORD STORMWATER IMPROVEMENTS <br /> OWNER's Contract No . 9219 ENGINEER's Contract No . 9219 <br /> ENGINEER : Indian River County Public Work's Department <br /> ENGINEER's CONSULTANT: Carter Associates , Inc. <br /> 1 . Original Contract Price : $ <br /> ' 2 . Net change by Change Orders and Written Amendments (+ or <br /> 2 . a Change Order No . 1 $ <br /> 2 . b Change Order No . 2 $ <br /> ' 2 . c Change Order No . 3 $ <br /> 2 . d Change Order No . 4 $ <br /> 2 . e Total change in Contract Price (2 . a + 2 . b + . . . + 2 . d ) $ <br /> ' 3 . Current Contract Price ( 1 plus 2e) : $ <br /> 4 . Total Work to date : <br /> 4 . a Percentage of Work completed to date : % <br /> ' 4 . b Total Work completed to date : $ <br /> 4 . c Total equipment and material stored to date : <br /> $ ( 1 ) <br /> 4 . d Total Work completed and stored to date : (4 . b plus 4 . c) $ <br /> 5 . Retainage (per Agreement) : <br /> 5 . a 10% of completed Work (0 . 10 x 4 . b ) . <br /> ' 5 . b 20 % of stored equipment and material (0 . 20 x 4 . c) : <br /> 5 . c Total Retainage (5 . a plus 5 . b ) : $ <br /> ' 6 . Total Work completed and stored to date less retainage <br /> (4 . d minus 5 . c) : $ <br /> 7 . Previous Payments : $ <br /> ' 8 . AMOUNT DUE THIS APPLICATION 6 MINUS 7) : $ <br /> ( 1 ) Attach detailed schedule and copies of all paid invoices . <br /> 1 CONTRACTOR' S CERTIFICATION : <br /> UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that ( 1 ) <br /> ' the labor and materials listed on this request for payment have been used in the <br /> construction of this Work and payment received from the last request for payment has <br /> been used to make payments to all subcontractors , laborers , materialmen and suppliers <br /> ' except as listed below; (2 ) title of all Work, materials and equipment incorporated in <br /> said Work or otherwise listed in or covered by this Application for Payment will pass to <br /> OWNER at time of payment free and clear of all Liens , security interests and <br /> ' 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 <br /> Work covered by this Application for Payment is in accordance with the Contract <br /> ' Documents and not defective ; and (4 ) If this Periodic Estimate is for a Final Payment to <br /> 00622 - Contractor's Application for Payment-2 <br /> ' <br /> 00622 - 1 <br /> F:\Public Works\Keithtvl\StomHvater Projects\Gifford Fast\l;onstrudion Contract\Bidding 6 Contract Documents\Bidding & Contract Documents\00622 - Contractor's <br /> Application <br /> for Payment-2.doc Rev. 05/01 <br />