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APPLICATION AND CERTIFICATE FOR PAYMENT TO (OWNER): PROJECT: Facilities Maintenance APPLICATION NO: 16 Distribution to : Indian River County Complex (SITE 2) RETAINAGE BALANCE ( Revision) O OWNER ( 1 ) 1840 25th Street PERIOD TO: 07/25/04 ❑x ARCHITECT (1 ) Vero Beach, FL 32960 ❑x CONTRACTOR (1 ) FROM (CONTRACTOR) : VIA (ARCHITECT) : Proctor Construction Company Hanson Engineers, Inc PROJECT NO : 9820 1401 Highway A-1 -A, Suite 301 1601 Belvedere Road , Suite 303 South Vero Beach , FL 32963 West Palm Beach, FL 33406 CONTRACT FOR: New Construction CONTRACT DATE : 08/06/02 CONTRACTOR 'S APPLICATION FOR PAYMENT CHANGE ORDER SUMMARY Application is made for Payment, as shown below, in connection with the Contract. Detail Sheet is attached. previous months by Owner ADDITIONS DEDUCTIONS 1 ORIGINAL CONTRACT SUM $ 4,877 ,988. 29 TOTAL 2. CHANGE ORDERS -289705. 13 Approved this Month 3 . CONTRACT SUM TO DATE $ 4, 8491283. 16 Number Date Approved 4 . TOTAL COMP & STORED TO DATE $ 4,617, 170. 37 -28705 . 13 (Subcontractors/OHP) 5 . RETAINAGE : a . 10% of Completed Work b . Less 95% Billed TOTAL RETAINAGE $ 6. TOTAL EARNED LESS RETAINAGE $ 4, 617, 170.37 (Line 4 less Line 5 Total) 7 . GENERAL CONDITIONS (No Retainage Held) $ 2009653. 19 TOTALS 0 . 00 a. LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 4, 7949737 .42 Net change by Change Orders -28 , 705 . 13 The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the 9. CURRENT PAYMENT DUE $ 23,086. 14 Work covered by this Application for Payment has been completed in accordance with the Contract Documents, 1 o . BALANCE TO FINISH , PLUS RETAINAGE 31 ,459 .60 that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current t shown herein is now due. CONTCT(SR: ' State of: Florida County of: Indian River ��a � ��e PATRICIA PITTS `''`.. � Subscribed and savor to befo me this 27th day Aug , db Commission Exp . May 22 , 2006 toQ Commission No . DD 119964 ti `, , Notary Pub �-' O Bonueo through western Surety Company By: tgti—�r "'Ill... Date: 08/27/04 Patricia itts Donald L. Tolliver, President/J udyA igg ins, Vice President My Com ission expires : 05/22/200 ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED $ In accordance with the Contract Documents , based on on-site observations and the data (Attach explanation if amount certified differs from the amount applied for) comprising the above application , the Architect certifies to the Owner that to the best of the Architect's knowledge , information and belief, the Work has progressed as indicated , the quality ARCHITECT: of the Work is in accordance with the Contract Documents, and the Contractor is entitled to By: Date: payment of the AMOUNT CERTIFIED. This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein . Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.