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INDIAN RIVER COUNTY, FLORIDA ATEERIIW� -o
APPLICATION FOR PAYMENT NO.
PROJECT NO: 9723 ACCOUNT NO:
PROJECT% Oslo Road -St 27th AVe 'and Five Lane Widening of Oslo Road (DFI13208 )
CONTRACTOR NAME/ADDRESS: nTCKFRSON FLORIDA- INC.
P.O. Drawer 719 Stuart Florida 34995
APPLICATION DATEc 8/3/99 FOR PERIOD ENDING 7/30/99
STATEMENT OF WORK
Original Contract Price $1.212.255.30 _ Materials Stored $ _
Net Change orders ;i7.36,.00) (Attach detailed schedule and paid invoices)
Current Contrast Price ;1,204,£3f39.1 _ Total Work/Materials to Date ; 1,155.314.10 ✓/
Work to Date: Lees 100 Retainage 57, $ 5 7,� X5.71 ✓
Under Original contract ;1 -16 _IIg7. 91 Sub Total �Cr COG $L\,
Under Change Order S_f7,583.80 Less Prior Payments $
Percent of Work Cc.npleted to date 96
EALANCS DUE THIS PAYMENT
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contractors certification
The undersigned CONTRACTOR hereby certifies that all items and amounts on the
face of this application for payment are correct; that all work has been
performed and/or materiaAA supplied in full accordance with the terms and
conditions of the contras .
The undersigned CQNTRACTOR hereby swears under penalty of perjury that (1) all
previous progress payments lreceived fSom the OWNER on account of work performed
underthe contract referred to above have been applied by the undersigned to
discharge in full All obligations of the undersigned incurred in connection with
work covered by prior Applications for Payment under said contract, being
Applications for Payment numbered 1 through 6 inclusive; and (2) all
materials and equipment incorporated in said pco)ect or otherwise listed in or
covPrpcs by thin Appli.cat;-on for Payment are tree and clear of all liens,_ claims,
security interests and encumbrances, t
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Dated Atioust 3 1999 CKE.RSON FLORIDA INC. ImMIK.P5!) I DATE.
(Contractor) pEKCT(ff;�/Lj`'jf'
71,
(Name t1 ) IK) •__ .._..-J
COUNTY OF INDIAN RIVER Ted 11. Tyson, PresidenEAc . •Jt ���fy. It67%751
STATE OF FLORIDA
Before me this 3rd day of Au(us t
, 1999 personally appeared
TTeedd �Jy�Qq_
known to me, who being duly sworn,
_____ ____
depo%ies and Hays that j(}(j(he s the
Prg.sident of the CONTRACTOR above
mentioned; that (a)he executed the above
Application for Psyment and statement
on behalf of naid CONTRACTOR; and that all
f, the statements contained herein are
true, correct and complete.
"r:' T•. Dawn T. Horne -Bounds
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MYCOMMISSION I CC704419 1XGif'ES
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My Commission Expires 11/19/99
Board of County Commission
Approvod for Payment
eth R. MaCht Chairman