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CAROL I BESANCON <br /> MY COMMISSION # DD 040435 <br /> day Of EXPIRES : September 27, 2005 <br /> Notary Public �i4a � gs,��y�o I80U3IWTAfiv Ft NOtarysarvice88orldirtg, lnc. <br /> My Commission expires : a /o - / <br /> CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLE) : <br /> I certify that I have checked and verify the above and foregoing Periodic Estimate for Partial <br /> Payment ; that to the best of my knowledge and belief it is a true and correct statement of the work <br /> performed and/or material supplied by the Contractor. <br /> Dated // �'' d '' ,�� - . 4 ><`d <br /> CHITEC''�T / ENGINEER ) SIGNATURE <br /> CERTIFICATION OF ENGINEER / INSPECTOR .• <br /> I have checked the estimate against the Contractor's Schedule of Amounts for Contract <br /> Payments and the notes and reports of my inspections of the project. It is my opinion that this <br /> statement of work performed and/or materials supplied is accurate , that the Contractor is observing <br /> the requirements of the Contract , and that the Contractor should be paid the amount requested <br /> above . <br /> Dated ' /�/ <br /> / ENGINEER ) SIGNATURE <br /> Accompanying Documentation : Itemized List of Labor Bid Items <br /> * * END OF SECTION <br /> Page 2 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 />