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' Documents and not defective ; and (4 ) If this Periodic Estimate is for a Final Payment to <br /> 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 <br /> Bye <br /> Y <br /> (CONTRACTOR) <br /> STATE OF FLORIDA <br /> ' COUNTY OF INDIAN RIVER <br /> Before me , a Notary Public , duly commissioned , qualified and acting , personally <br /> 1 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 , 20_ <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 /> payments) 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 /> ' a corporation , in accordance with Performance Bond Number , hereby <br /> consents to payment by the OWNER to the CONTRACTOR, for the amounts specified <br /> ' 00622 - Contractor's Application for Payment ADDENDUM #2 — ADDENDUM #1 <br /> 00622 - 2 <br /> F:\Public WorksWeithwOommater Projects\Gifford East\Construction Contract\Bidding & Contract Documents\Bidding & Contract Documents\00622 - Contractors Application <br /> for Payment ADDENDUM #2.doc Rev. 05101 <br />