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A 9 { CONTRACTOR'S CERTIFICATION : UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that ( 1 ) the � r 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 Work covered by this Application for Payment is in accordance with the Contract Documents and not defective and (4) If this Periodic Estimate is for a Final payment to project or improvement, I further certify that all persons doing work upon ' = or furnishing materials or supplies for this project or improvement under this foregoing contract have been paid in full , and that all taxes imposed by Chapter 212 Florida Statutes , (Sales and t . Use Tax Act, as Amended ) have been paid and . discharged , and that I have no claims against the OWNER Dated 70 0q t COCTOR) By: o (OT State of County of 1 BRANDI BOLIMG� ? Subscribed and swum to foe m XFtis State of Florida y � j Notary Public , da of 22 + my comm . expires Aug . 12 , 2005 . comm . No . DD048767 Notary PublicID 951174 11A)/ Commission @Xplr@ Bonded Thru Service Insurance ournpany, Inc NOTICE OF NON-PA YMENT. If one or mo �i of Non-Payment" or "Notice to Owner' is received by the OWNER, no further payments will be approved until non- payment(s) have been satisfied and a "Lien Waiver" for each "Notice " has been submitted to the OWNER. Upon request, CONTRACTOR shall furnish acceptable evidence that all such claims have been satisfied. The CONTRACTOR may, with consent of Surety and indemnirication of the OWNER against any claims, receive j payment for work for which there is an outstanding "Notice of Non-Payment" or "Notice to Owner. " CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLE) : I certify that I have checked and verify the above and foregoing Periodic Estimate for Partial Payment; that to the best of my knowledge and belief it is a true nd correct statement of the work performed and/or material supplied by the Co r. Dated 4102 7000, (ARCHCT / R) SIGNATURE Y 00622 -2 0219-00622 - Contractor's Application for Payment f `'" PlEnpineerinp�Capital Prolects10219-10tchlnp Station Trallhead10219 IQtchinp-Contract Docs10219.00M - Contractors Application for Payment.doc Rev. 05/01