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SECTION 00622 - CONTRACTOR' S APPLICATION FOR PAYMENT Application for Payment No , For Work Accomplished through the period of through To : Indian River CountyOWNER (OWNER) From : (CONTRACTOR) Contract: EAST GIFFORD STORMWATER IMPROVEMENTS OWNER's Contract No , 9219 ENGINEER's Contract No . 9219 ENGINEER : Indian River County Public Work's Department ' ENGINEER's CONSULTANT : Carter Associates , Inc. 1 . Original Contract Price : $ 2 . Net change by Change Orders and Written Amendments (+ or 2 . a Change Order No . 1 $ 2 . b Change Order No . 2 $ ' 2 . c Change Order No . 3 $ 2 . d Change Order No . 4 $ 2 . e Total change in Contract Price (2 . a + 2 . b + . . . + 2 . d ) $ 3 . Current Contract Price ( 1 plus 2e ) : $ 4 . Total Work to date : 4 . a Percentage of Work completed to date : 4 . b Total Work completed to date : $ 4 . c Total equipment and material stored to date : $ ( 1 ) 4 . d Total Work completed and stored to date : (4 . b plus 4 . c) $ 5 . Retainage ( per Agreement) : 5 . a 10 % of completed Work (0 . 10 x 4 . b) : $ 5 . b 20 % of stored equipment and material (0 .20 x 4 . c) : 5 . c Total Retainage (5 . a plus 5 . b ) : $ ' 6 . Total Work completed and stored to date less retainage (4 . d minus 5 . c) : $ 7 . Previous Payments : $ ' 8 . AMOUNT DUE THIS APPLICATION 6 MINUS 7) : $ ( 1 ) Attach detailed schedule and copies of all paid invoices . 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 clear 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 00622 - Contractor's Application for Payment ADDENDUM #1 — ADDENDUM #1 00622 - 1 F:\Public Works\KeIthMlStomHvater Projects\Gifford Eest\ConsWction Contractl8idding & Contract Documents\Bldding & Contrail Documents\00622 - Contractors Application for Payment ADDENDUM #1 .doc Rev. 05/01