2003-118A.1 - Laserfiche WebLink

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the 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 that I have no claims against the OWNER . Dated By: ' (CONTRACTOR) STATE OF FLORIDA COUNTY OF INDIAN RIVER ' Before me , a Notary Public , duly commissioned , qualified and acting , personally appeared , to me well known , who being by me first duly sworn upon oath , says that he/she is the President of the Contractor above mentioned : ; the he/she executed the above Application for Payment and statement on behalf of said CONTRACTOR ; and that all of the statements contained herein are true , correct and complete . Subscribed and sworn to before me this _ day of 120 Notary Public, State of Florida ' My Commission Expires : ' Accompanying Documentation . 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. " ' [The Remainder of This Page Was Left Blank Intentionally] y] 00622 - Contractor's Application for Payment-2 ' 00622 - 2 F:\Public Works\KeithMlStomHvater Projects\Gifford East\ConsUuetion Conlrect\Bidding & Contrail Documents\Bldding & Contract Documents\00622 - Contractor's Application for Payment-2.doc Rev. 05/01