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to <br />(TO BE COMPLETED BY A FLORIDA PROFESSIONAL SURVEYOR AND MAPPER RETAINED <br />BY THE CONTRACTOR AND TO ACCOMPANY CONTRACTOR'S FINAL APPLICATION FOR <br />1` PAYMENT) <br />I CERTIFY that I am a Florida Professional Surveyor and Mapper retained by: <br />r <br />r' (Insert name of CONTRACTOR) <br />Who is the CONTRACTOR for the following Project: <br />0 <br />PROJECT NAME: CR 512, PHASE IV ROADWAY IMPROVEMENTS <br />INDIAN RIVER COUNTY PROJECT # 9611 <br />W <br />I FURTHER CERTIFY that I have personally performed the survey work for the preparation <br />of Record Drawings for the CONTRACTOR for this project or that such work was performed under <br />my direct control and supervision. <br />I FURTHER CERTIFY that all constructed elevations and locations of the Work are in <br />conformance with the Contract Documents, except for discrepancies listed below. <br />r <br />0 <br />W <br />r <br />[Attach additional sheets as <br />CERTIFIED BY: <br />Printed Name: <br />r' Florida Professional Surveyor and Mapper Registration Number: <br />Date Signed and Sealed by Professional Surveyor and Mapper: <br />Company Name: <br />W Company Address: <br />an Telephone Number: <br />No <br />(SURVEYOR'S SEAL) <br />00634 - Professional Surveyor and Mapper's Certification as to Elevations and Locations of the Work REV 04-07.doc <br />00634-1 <br />FaEngirwetiiglCaplal Projects15611-CR 512 Widenin;W11 CR 512 PHASE MConnac Documents1W634 - Praressional Smveyor and Mappefs Certification as to Elevations <br />and Laratbns of the Won[ REV 04-07.doc <br />