HomeMy WebLinkAbout2009 Subcontractors Final Release SECTION 00622 - CONTRACTOR'S APPLICATION FOR PAYMENT
Application For Payment No 1
For work accomplished through the period of 1-Feb-09 _ through 28-Feb-09
To: City of Sebastian
From; H& 0 Construction Co., Inc
Owner's Contract No. Engineers Contract No.
Engineer: Schulke, Bitt le and Stoddard LLC
I v
1. ORIGINAL CONTRACT PRICE $ 1,193,903.02
2. Net change by Change Orders
2a. Change Order#1 $ -
2b. Change Order#2 S
2c. Change Order#3 $ -
2d. Change Order#4 $ -
Total Change in Contract Price S -
3. CURRENT CONTRACT PRICE (Line 1+1- 2) $ 1,193,903.02
4. TOTAL COMPLETED & STORED TO DATE $ 148,349.00
(Column J on G703)
5. Retainage:
10% of Completed Work $ -
(Columns G + H on G703)
20% of Stored Material _$ -
(Column I on G703)
Total Retainage (Line 5a + 5b c
Total in Column L of G703) $ 14,834.90
6. TOTAL EARNED LESS RETAINAGE $ 133,514.10
(Line 4 less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
(Line 6 from prior Certificate) $ _
8. CURRENT PAYMENT DUE
S 133,514.10
9. BALANCE TO FINISH, INCLUDING RETAINAGE
(Line 3 less Line 6) 1,060,388.92
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, rnaterialmen 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; and (3)all Work covered by this Application for Payment
is in accordance with the Contract Documents and not defective.
31 !°?
Dated �/�^�� ^/��^—~�-
� ^ By:---- ^/ �� ~ ' '� /^^ ' '—
, ,
u/,L����° , /A CO,~�
STATE OF FLORIDA
COUNTY OF INDIAN RIVER
Before me, a Notary Public, duly commissioned, qualified and acting, personally appeared Michael
DiGiacomo , to me well knmwn, who being by me first duly sworn upon oath, says that he/she is the
President of the Contractor above mentioned; the he/she executed the above Application for Payment
and statement on behalf of said CONTRACTOR; and that all of the statements contained herein are
true, rect and complete. Subscribed and sworn to before me this day of A46 .
Notary Public, State ofF|oh*a
MyComm�o�nEx�nao: 7^,_ mwmu
°"COMMON"vv 800041 !
s.*5. EXPIRES:filbtuany #01
Accompanying Documentation:
—Jr) -_'-^
[ ./!eL°`e, L^
NOTICE F NON-PAYMENT. If one or more "Notice of Non-Paymen/"or"Notice to Owner"is
naceived by the OWNER, no further payments will be approved until non-payment(s) have been
satisfied and a "Lien Waiver for each Woffce'has been submitted to The OWNER. Upon request,
CONTRACTOR shall furnish acceptable evidence(hat all such claims have been satisfied The
CONTRACTOR may, with consent of Sum&and indeniticmtiomo/th*0NNERagawxYanycla/ms,
receive payment for work for which there is an outstanding "Notice of Non-Payment' or"Notice to
Owner"
^ °°"° ~°***°°°°^°^....-^=rk^
[ERTIF|CATyONOF ENGINEER:
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 and correct statement of the �brk performed
and/or ma�do}Supplied by the(�nn\,mu{or ~
�
Dated
SIGNATURE___
CERTIFICATION OF NGINEER/INSPECTOR:
I have checked the estimate against the Contractor's Schedule of Amounts for Contract Payments and
the notes and reports of my inspections of the project. It is my opinion that this statement of work
performed and/or materials supplied is accurate, that the Contractor is observing the requirements of
the Contract,and that the Contractor should be paid the amount requested above.
Dated ��'�NATURE
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