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SECTION 00622 — CONTRACTOR' S APPLICATION FOR PAYMENT t FOR PART 1 OF THE CONTRACT Revised January 9 , 2004 per Addendum No 1A 1 Application for Payment No . For Work Accomplished through the period of through ' To : Indian River County (OWNER) From : (CONTRACTOR) Contract: HARMONY OAKS MITIGATION PROJECT — PART 1 OF THE CONTRACT OWNER's Contract No . 9219A ENGINEER's Contract No . ENGINEER: Indian River County Public Work's Department ' 1 . Original Contract Price for PART 1 of the Contract: 2 . Net change by Change Orders and Written Amendments (+ or -) : ' 2 . a Change Order No . 1 ($ ) 2 . b Change Order No . 2 ($ ) 2 . c Change Order No . 3 ($ ) ' 2 . d Change Order No . 4 ($ ) 2 . e Total change in Contract Price (2 . a + 2 . b + . . . 2 . n ) ($ ) 3 . Current Contract Price ( 1 plus 2e ) : $ ' 4 . Total Work to date : 4 . a Percentage of Work completed to date : 4 . b Total Work completed to date : $ ' 4 . c Total equipment and material stored to date : $ ( 1 ) 4 . d Total Work completed and stored to date : (4 . b plus 4 . c) $ ' 5 . Retainage ( per Agreement) : 5 . a 10 % of completed Work (0 . 10 x 4 . b ) : ' 5 . b 20 % of stored equipment and material (0 . 20 x 4 . c) : 5 . c Total Retainage (5 . a plus 5 . b ) : $ 6 . Total Work completed and stored to date less retainage (4 . d minus 5 . c) : $ 7 . Previous Payments : $ 8 , AMOUNT DUE THIS APPLICATION 6 minus 7) : $ ' ( 1 ) Attach detailed schedule and copies of all paid invoices . CONTRACTOR' S CERTIFICATION : ' UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that 1 the labor and materials listed on this request for payment have been used in the ' construction of this Work and payment received from the last request for payment has been used to make payments to all subcontractors , laborers , materialmen and suppliers except as listed below; (2 ) title of all Work , materials and equipment incorporated in ' said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens , security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER ' indemnifying OWNER against any such Lien , security interest or encumbrance ) ; (3 ) all Addendum #1 - 00622 - Contractor's Application for Payment - Part 1 00622 - 1 F.\Public WorksWeithmStormwater Projects\Harmony Oaks Mitigation Project\Construction Contract\Bidding and Construction Contract Documents\Hddendum #1 - 00622 - Contractor's Application for Payment - Part 1 .doc Rev. 05/01