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Work covered by this Application for Payment is in accordance with the Contract <br /> ' 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 <br /> materials or supplies for this project or improvement under this foregoing contract have <br /> ' been paid in full , and that all taxes imposed by Chapter 212 Florida Statutes , (Sales <br /> and Use Tax Act , as Amended ) have been paid and discharged , and that I have no <br /> claims against the OWNER . <br /> Dated <br /> By: <br /> (CONTRACTOR) <br /> ' STATE OF FLORIDA <br /> COUNTY OF INDIAN RIVER <br /> ' Before me , a Notary Public , duly commissioned , qualified and acting , personally <br /> appeared , to me well known , who being by me first duly <br /> sworn upon oath , says that he/she is the President of the Contractor above mentioned : ; <br /> the he/she executed the above Application for Payment and statement on behalf of said <br /> CONTRACTOR ; and that all of the statements contained herein are true , correct and <br /> complete . Subscribed and sworn to before me this _ day of , 20_ <br /> ' Notary Public , State of Florida <br /> ' My Commission Expires : <br /> ' Accompanying Documentation : <br /> ' NOTICE OF NON-PAYMENT. If one or more "Notice of Non -Payment " or "Notice to <br /> Owner" is received by the OWNER, no further payments will be approved until non- <br /> payments) have been satisfied and a "Lien Waiver" for each "Notice " has been <br /> ' submitted to the OWNER. Upon request, CONTRACTOR shall furnish acceptable <br /> evidence that all such claims have been satisfied. The CONTRACTOR may, with <br /> consent of Surety and indemnification of the OWNER against any claims, receive <br /> ' payment for work for which there is an outstanding "Notice of Non -Payment" or "Notice <br /> to Owner. " <br /> ' [The Remainder of This Page Was Left Blank Intentionally] <br /> Addendum #1 - 00622 - Contractor's Application for Payment - Part 1 <br /> ' <br /> 00622 - 2 <br /> F:\Publie WorksU(eithM\Stomwoater Projects\Harmony Oaks Mitigation Project\Construction Contract\Bidding and Construction Contract DocumentSWddendum #1 - 00622 <br /> - <br /> Contractor's Application for Payment - Part 1 .doc Rev. 05/01 <br />