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SECTION 00622 - Contractor's Application for Payment <br /> Application for Payment No . <br /> For Work Accomplished through the period of through <br /> To : Indian River Countv Solid Waste Disposal District (OWNER ) <br /> From : (CONTRACTOR) <br /> Contract : <br /> Project : <br /> OWNER's Contract No . ENGINEER ' s Contract No . <br /> ENGINEER <br /> 1 . Original Contract Price : $ <br /> 2 . Net change by Change Orders and Written Amendments ( + or -) : $ <br /> 3 . Current Contract Price ( 1 plus 2 ) : $- <br /> 4 . Total completed and stored to date : $ <br /> 5 . Retainage ( per Agreement) : <br /> of completed Work : $ <br /> of stored material : $ <br /> Total Retainage : $ <br /> 6 . Total completed and stored to date less retainage (4 minus 5) : <br /> 7 . Less previous Application for Payments : $ <br /> 8 . DUE THIS APPLICATION ( 6 MINUS 7) : <br /> CONTRACTOR ' S CERTIFICATION : <br /> The undersigned CONTRACTOR certifies that ( 1 ) all previous progress payments received <br /> from OWNER on account of Work done under the Contract referred to above have been <br /> applied on account to discharge CONTRACTOR 's legitimate obligations incurred in connection <br /> with Work covered by prior Applications for Payment numbered 1 through inclusive ; (2 ) <br /> title of all Work , materials and equipment incorporated in said Work or otherwise listed in or <br /> covered by this Application for Payment will pass to OWNER at time of payment free and clear <br /> of all Liens , security interests and encumbrances (except such as are covered by a Bond <br /> acceptable to OWNER indemnifying OWNER against any such Lien , security interest or <br /> encumbrance) ; (3 ) all Work covered by this Application for Payment is in accordance with the <br /> Contract Documents and not defective and (4) If this Periodic Estimate is for a Final payment to <br /> project or improvement , I further certify that all persons doing work upon or furnishing materials <br /> or supplies for this project or improvement under this foregoing contract have been paid in full , <br /> and that all taxes imposed by No . 212 Florida Statutes , ( Sales and Use Tax Act , as Amended ) <br /> have been paid and discharged . <br /> Dated <br /> (CONTRACTOR) <br /> By : <br /> State of <br /> County of <br /> Subscribed and sworn to before me this <br /> day of <br /> Notary Public <br /> My Commission expires : <br /> 6706 - 38666\2/5 /04 00622- 1 VRB <br />