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ti <br /> SECTION 00622 - Developer Contractor Application for Payment <br /> Application for Payment No . 3 , 100 % Complete <br /> For Work Accomplished through the period of April 22 through July 24 2003 <br /> To : Indian River County (OWNER ) <br /> From : George E . French , Utilities Labor Contractor (CONTRACTOR OR ENGINEER) <br /> Project Name : 35th Ave & 34th Ave Grovenor Estates Water Services Relocation <br /> COUNTY WIP NO . : 471 . 169000 . 02524 <br /> ENGINEER OF RECORD : Gordon E . Sparks , P . E . . <br /> 1 . Original Contract Price : $41 , 419 , 02 <br /> 2 . Net change by Change Orders and Written Amendments ( + or - ) : ($ 79091 . 88 ) <br /> 3 . Current Contract Price ( 1 plus 2 ) : $489510 . 90 <br /> 4 . Total completed and stored to date $48 , 510 , 90 <br /> 5 . Retainage ( per Agreement) : <br /> 10 % of completed Work : $4 , 851 . 09 <br /> 0 % of stored material : $0 . 00 <br /> Total Retainage : $4 , 851 , 09 <br /> 6 . Total completed and stored to date less retainage (4 minus 5 ) : $43 , 659 . 81 <br /> 7 . Less previous Application for Payments : $379186 . 60 <br /> 8 . DUE THIS APPLICATION (6 MINUS 7) : $ 11 , 324 . 30 <br /> (*) If applicable, an Itemized list of labor and/or materials furnished and installed I s attached. <br /> CONTRACTOR'S CERTIFICATION : <br /> The undersigned CONTRACTOR certifies that ( 1 ) all previous progress payments received from <br /> OWNER on account of Work done under the Contract referred to above have been applied on <br /> account to discharge CONTRACTOR 's legitimate obligations incurred in connection with Work <br /> covered by prior Applications for Payment numbered 1 through 2 inclusive ; (2 ) title of all <br /> Work , <br /> materials and equipment incorporated in said Work or otherwise listed in or covered by this <br /> Application for Payment will pass to OWNER at time of payment free and clear of all Liens , security <br /> interests and encumbrances (except such as are covered by a Bond acceptable to OWNER <br /> indemnifying OWNER against any such Lien , security interest or encumbrance ) ; (3 ) all Work <br /> covered by this Application for Payment is in accordance with the Contract Documents and not <br /> defective and (4 ) If this Periodic Estimate is for a Final payment to project or improvement , I further <br /> certify that all persons doing work upon or furnishing materials or supplies for this <br /> project or <br /> improvement under this foregoing contract have been paid in full , and that all taxes imposed by No . <br /> 212 Florida 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 �'' /� � v _ <br /> ACTOR) <br /> State of <br /> County of <br /> Subscribed and sworn to before me this Attachment <br /> Page 1 of 2 <br /> F:\Utilities\UTILITY - ENGINEERING\Projects - Utility Construction Permits\IRC - 34th Ave. SW - 35th Ave SW Utility Relocations in Grovenor Estates <br /> Subdivision UCP#2293\00622 - <br /> Developer Contractor Application for Payment.doc Rev. 07/01 <br />