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the project or improvement , I further certify that all persons doing work upon or <br /> ' furnishing materials or supplies for this project or improvement under this foregoing <br /> contract have been paid in full , and that all taxes imposed by Chapter 212 Florida <br /> Statutes , ( Sales and Use Tax Act, as Amended ) have been paid and discharged , and <br /> that I have no claims against the OWNER . <br /> Dated By: <br /> ( CONTRACTOR) <br /> STATE OF FLORIDA <br /> COUNTY OF INDIAN RIVER <br /> rBefore me , a Notary Public , duly commissioned , qualified and acting , personally <br /> appeared , to me well known , who being by me first duly <br /> sworn upon oath , says that he/she is the President of the Contractor above mentioned : ; <br /> the he/she executed the above Application for Payment and statement on behalf of said <br /> CONTRACTOR ; and that all of the statements contained herein are true , correct and <br /> complete . Subscribed and sworn to before me this _ day of 920 <br /> Notary Public , State of Florida <br /> ' My Commission Expires : <br /> Accompanying Documentation . <br /> NOTICE OF NON-PAYMENT. If one or more "Notice of Non-Payment " or "Notice to <br /> Owner" is received by the OWNER, no further payments will be approved until non - <br /> ' <br /> payment(s) have been satisfied and a "Lien Waiver" for each "Notice " has been <br /> submitted to the OWNER. Upon request, CONTRACTOR shall furnish acceptable <br /> evidence that all such claims have been satisfied. The CONTRACTOR may, with <br /> ' consent of Surety and indemnification of the OWNER against any claims, receive <br /> payment for work for which there is an outstanding "Notice of Non-Payment" or "Notice <br /> to Owner. " <br /> SURETY' S CONSENT OF PAYMENT TO CONTRACTOR : <br /> The Surety, <br /> f <br /> a corporation , in accordance with Performance Bond Number , hereby <br /> consents to payment by the OWNER to the CONTRACTOR , for the amounts specified <br /> in this CONTRACTOR' s APPLICATION FOR PAYMENT . <br /> 00622 - Contractor's Application for Payment ADDENDUM #1 — ADDENDUM #1 <br /> 00622 - 2 <br /> F:1Publlc Works\KetthM\Storrtnvater Projects\Gifford East\ConsWction ContracflBldding & Contract Documents\Bidding & Contract Documents\00622 - Contredor's <br />Application <br /> for Payment ADDENDUM #t .doc Rev. 05/05 <br />