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NOV-29-1999 14:06 561 267 4660 561 287 4660 P.02i02
INDIAN RIVER COUNTY, FLORIDA
APPLICATION FOR PAYMENT NO.19 - Revised
PROJECT N0 8823 ACCOUNT NO:
PROJECT: Kings Highway 58th Ave. 2§th St. to 26th St.
CONTRACT HAMF/ADDRESS:
APPLICATION DATE:11%8%91 FOR PERIOD ENDING 9/25/99
[' ntrartors Certification
The undersigned CONTRACTOR hereby certifies that all items and amounts on the
face of this appliction for payment are correct; that all work has been
performed and/or materials supplied in full accordance with the terms and
conditions of the contract.
The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all
previous progress payments received from the OWNER on account of work performed
under the contract referred to above have been applied by the undersigned to
discharge in full all obligations of the undcrsigned incurred in aomneotion with
work covered by prior Applications for Payment under said contract, being
Applications for Payment numbered 1 through inclusive; and (2) all
materials and equipment incorporation in said project or otherwise listed in or
covered by this Application for Payment are free and clear of all liens, claims
security interests and encumbrances.
Dated November 8 , 1999
COUNTY OF MARTIN
STATE OF FLORIDA
DI RIDA, iC.
(Contr
BY:
(Rage/Title)
Ted H. Tyson, President
Before me this 8th day of November 1999, personally appeared
Ted H. Tyson , known to me, who being duly sworn,
deposes and says that he is the P-2idP11- of the CONTRACTOR above
mentioned: that he executed the above Application for Payment and statement
on behalf of said CONTRACTOR: and that all of the statements contained herein are
true, correct and complete. 1'2
Board ofCountyCommission Not6zy Public
Approved for Payment i crystalMonocandke
`K MYC0MMISS"iCCg24V2 em
12-7- Date; Apr➢Q 2003
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STATEMENT OF VORK
Original Contract Price
$
5,977,966.93_
Materials Stored S 18,819.12
detailed schedule and paid invoices)
Net Change Orders
$
212,857.60
(Attach
Total Vork/Materials to date 55,678,673.55
6,190,824.53
Current Contract Price
$
Less 5% Retainage 8 203 33-68
>Jork to Date:
Under Original Contract
S
5 306,425.40
Sub Total $5.394, 39.67
Under Change Order
s
353,425.03
Less Prior Applications $5,123,560.96
% Vork Completed to date
91%
BALANCE DUE THIS APPLICATION a 271,178.91
[' ntrartors Certification
The undersigned CONTRACTOR hereby certifies that all items and amounts on the
face of this appliction for payment are correct; that all work has been
performed and/or materials supplied in full accordance with the terms and
conditions of the contract.
The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all
previous progress payments received from the OWNER on account of work performed
under the contract referred to above have been applied by the undersigned to
discharge in full all obligations of the undcrsigned incurred in aomneotion with
work covered by prior Applications for Payment under said contract, being
Applications for Payment numbered 1 through inclusive; and (2) all
materials and equipment incorporation in said project or otherwise listed in or
covered by this Application for Payment are free and clear of all liens, claims
security interests and encumbrances.
Dated November 8 , 1999
COUNTY OF MARTIN
STATE OF FLORIDA
DI RIDA, iC.
(Contr
BY:
(Rage/Title)
Ted H. Tyson, President
Before me this 8th day of November 1999, personally appeared
Ted H. Tyson , known to me, who being duly sworn,
deposes and says that he is the P-2idP11- of the CONTRACTOR above
mentioned: that he executed the above Application for Payment and statement
on behalf of said CONTRACTOR: and that all of the statements contained herein are
true, correct and complete. 1'2
Board ofCountyCommission Not6zy Public
Approved for Payment i crystalMonocandke
`K MYC0MMISS"iCCg24V2 em
12-7- Date; Apr➢Q 2003
'.Ziw' eorpEonaumorreaeuwa+c;Nc
,h�wmanW