01290a 00 62 76 Application for Payment rev 04 01 10

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01290a 00 62 76 Application for Payment rev 04 01 10 Powered By Docstoc
					                                                               The School Board of Broward County, Florida
                                                                   Office of Facilities and Construction
                                                                     1643 North Harrison Parkway, Bldg. H
                                                                              Sunrise, FL 33323                                                                            (754) 321-1500

                                           Document 01290a (00 62 76)-Application for Payment
To:                     The School Board of Broward County, Florida                                                                                  SBBC
                                                                                                                                                     Purchase
                                                                                                Application                 Period                   Order
                                                                                                       No.:                    To:                   No.:
                        (Owner via Project Consultant)
Project No:
Project Title:                                                                               Contractor:
Facility Name:

Change Order Summary                                                                         Application is made for Payment, as shown below, in connection with the Contract.
Change Orders approved by the                                                                The Contractors updated Document 00435-Schedule of Values, is attached as a
                                                Additions             Deductions
School Board in previous months.                                                             continuation/detail sheet.
                            Total:
                                                                                             1. ORIGINAL CONTRACT SUM                                             $

Approved this Month:                                                                         2. NET CHANGE BY CHANGE ORDERS                                       $
Number           Date Approved                                                               3. CONTRACT SUM TO DATE
                                                                                                (Line 1 plus or minus line 2)                                     $
                                                                                             4. TOTAL COMPLETED AND STORED TO DATE
                                                                                                (Column H of Document 00435)                                      $
                                  Totals                                                     5. RETAINAGE
                                              Net change by                                     a.       % of Completed Work $
                                             Change Orders:                                         (Column E + F of Document 00435)
The undersigned contractor certifies that to the best of the Contractor’s knowledge,            b.       % of Completed Work $
information and belief the Work covered by this application for payment has been completed          (Column E + F of Document 00435)
in accordance with the Contract Documents, that all amounts have been paid by the
Contractor for Work for which previous Certificates for Payment were issued and payments        Total Retainage (Line 5a + 5b or total in Column K on
received from the Owner and that current payment shown herein is now due.                           Document 00435)                                               $
    Contractor:                                                                              6. TOTAL EARNED LESS RETAINAGE
                                                                                                (Line 4 less Line 5 Total)                                        $
   By: (Signature)                                               Date:
                                                                                             7. LESS PREVIOUS CERTIFICATES FOR PAYMENT
                                                                                                (Line 6 from previous certificate)                                $
                                                                                             8. CURRENT PAYMENT DUE
Notarization                                State of Florida         County
                                                                                                (Enter this amount on Line 10 next page)                          $
Sworn Before me on this               day of       ,     .                                   9. BALANCE TO FINISH, PLUS RETAINAGE
                                                               Commission Expires:              (Line 3 less Line 6)                                              $
Notary Public:
_____________________________________________________________________________________________________
The School Board of Broward County, Florida                                                                                                          Section 01290a (00 62 76)
[Specifier replace this line with SBBC project number and name]                                                                                         Application for Payment
[Specifier replace this line with Project Consultant’s name]                                                                         [Specifier replace this line with issue date]
((Specifier leave this line)) SBBC Design & Material Standards, January 01, 2010 Edition, rev. 04-01-10 RW)                                                           Page 1 of 2
                                               Document 01290a-Application for Payment

Project Consultant’s Certificate for Payment
                                                                               OWNER’S APPROVAL
                                                                               10. AMOUNT APPROVED
In accordance with the Contract Documents, based on on-site                    (Attach explanation if amount approved differs from the amount certified above.)
observations and the data comprising the above application, the
Project Consultant’s certifies to the Owner that to the best of his            Approved for Payment by:
knowledge, information and belief, the Work has progressed as
indicated, the quality of the Work is in accordance with the                         Project Manager:
Contract Documents, and the Contractor is entitled to payment in
the AMOUNT CERTIFIED.                                                          By:                                                    Date:
                                                                                                        (Signature)


AMOUNT CERTIFIED                                     $                               Executive Director, Project Management,
(Attach explanation if amount certified differs from the amount applied              or Designee:
for.)
Project Consultant
                                                                               By:                                                    Date:
By:                                                   Date:                                             (Signature)
                    (Signature)

This Certificate is not negotiable. The AMOUNT CERTIFIED is payable                  Deputy Superintentant
only to the Contractor named herein.         Issuance, payment and
acceptance of payment are without prejudice to any rights of the Owner
or Contractor under this Contract.                                             By:                                                    Date:
                                                                                                        (Signature)

                                                                               This Approval is not negotiable. The AMOUNT APPROVED is payable only to the
                                                                               Contractor named herein. Issuance, payment and acceptance of payment are without
                                                                               prejudice to any rights of the Owner or Contractor under this Contract.




_____________________________________________________________________________________________________
The School Board of Broward County, Florida                                                                                               Section 01290a (00 62 76)
[Specifier replace this line with SBBC project number and name]                                                                              Application for Payment
[Specifier replace this line with Project Consultant’s name]                                                              [Specifier replace this line with issue date]
((Specifier leave this line)) SBBC Design & Material Standards, January 01, 2010 Edition, rev. 04-01-10 RW)                                                Page 2 of 2

				
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