19-Doc 00 62 76 - Application for Payment.pdf

DOCUMENT 00 62 76

APPLICATION FOR PAYMENT NO.

TO: (OWNER)

Contract for:

OWNER'S Contract No. ENGINEERs Project No:

For Work accomplished through the date of

Unit Price Quantity Amount

Total (Original Contract) $

Change Order No. 1 $

Change Order No. 2 $

Accompanying Documentation: GROSS AMOUNT DUE. . . . . . . . . . . . . $

LESS % RETAINAGE . .. . . . . $

AMOUNT DUE TO DATE . . . . . . . . . . . $

LESS PREVIOUS PAYMENTS . . . . . . . $

AMOUNT DUE THIS APPLICATION . . .$

CONTRACTOR's Certification:

Dated:

CONTRACTOR

By:

(authorized signature)

Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

Dated: , 20___

ENGINEER

By:

(authorized signature)

The undersigned CONTRACTOR certifies that: (1) all previous progress payments received from OWNER on account of Work done under the Contract referred to above have been applied to discharge in full all obligations of CONTRACTOR incurred in connection with Work covered by prior Applications for Payment numbered 1 through _________ inclusive; (2) title to 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, claims, security interest and encumbrances (except such as are covered by Bond acceptable to OWNER indemnifying OWNER against any such lien, claim, security interest or encumbrance);

and (3) all Work covered by this Application for Payments is in accordance with the Contract Documents and not defective as that term is defined in the Contract Documents.

Amount

ITEM

Quantity

MIRIA

124 Easton Road Demolition

2025-01189.01

CONTRACTORs Schedule of Values

2025-01189.01

Work Completed

EJCDC Form C-620

APPLICATION FOR PAYMENT

00 62 76-1