Construction_Forms_-_Exhibit_to_Agreement_10.14.26.pdf

SEMINOLE COUNTY BOARD OF COUNTY COMMISSIONERS

CONSTRUCTION FORMS

EXHIBIT TO THE AGREEMENT

TO BE PROVIDED TO THE CONTRACTOR WITH THE AGREEMENT

Application for Payment ..................................................................................................... C-01 Continuation Sheet for Application for Payment .................................................................. C-01 (2)

Change Order Form ............................................................................................................ C-02 Shop Drawing Submittals................................................................................................... C-03

Authorized Field Change (AFC) ......................................................................................... C-04

Certificate of Substantial Completion................................................................................ C-05

Certificate of Final Completion .......................................................................................... C-06

Contractor’s Release .......................................................................................................... C-07

Contractor’s Waiver of Lien (Partial) ................................................................................. C-08

Subcontractor’s Waiver of Lien (Partial) ........................................................................... C-09

Contractor’s Waiver of Lien (Final and Complete)............................................................ C-10

Subcontractor’s Waiver and Release of Lien (Final) ........................................................ C-11

Consent of Surety to Final Payment .................................................................................. C-12

Any manipulations of these documents would be grounds for fraud and misrepresentation.

APPLICATION FOR PAYMENT

Contract for: Payment Application No.:

County Contract No.: CIP No.:

CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS

Total changes approved in previous months by County $ $ Total approved this month $ $

TOTAL $ $

NET CHANGES by Change Order $

1. ORIGINAL CONTACT SUM ………………………………………………………………. $

2. NET CHANGE BY CHANGE ORDER .…………………………………………………… $

3. CONTACT SUM TO DATE (Line 1 & Line 2) ……………………………………………. $

4. TOTAL COMPLETED AND STORED TO DATE.……………………………………….. $

5. RETAINAGE:

(a) % of Completed Work ............................................. $

(b) % of Stored Material ............................................... $

Total Retainage (Lines 5a + 5b, or Total in Column 1) ……………………………….. $

6. TOTAL EARNED LESS RETAINAGE .……………………………………………………. $

7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ……………………………………. $

(Line 6 from Prior Payment Application)

8. CURRENT PAYMENT DUE .................................................................................................. $

9. BALANCE TO FINISH INCLUDING RETAINAGE (Line 3 minus Line 6)………………. $ The undersigned Contractor certifies that (1) all previous payments for Work performed have been applied to discharge in full all obligations on the Contractor incurred in connection with Work covered by prior payment applications (1 through _ ) under this Agreement; (2) all Materials and Equipment incorporated in the project are free and clear of liens, security interests and encumbrances; (3) all previous payments have been applied to pay in full, minus retainage, all amounts owed to its subcontractors and suppliers; (4) all information provided is true and accurate.

CONTRACTOR: DATE:

By: (Print) (Signature)

STATE OF FLORIDA

COUNTY OF

Sworn to (or affirmed) and subscribed before me by means of □ physical presence or □ online notarization, this day of , 20 , by .(name of person making statement)

Signature of Notary Public – State of Florida Print/Type/Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification Identification Type:

COUNTY: In accordance with the Contract Documents, the undersigned recommend payment as presented.

Engineer/Professional: Date:

Project Manager: Date:

C-01 – Application for Payment (Rev 10.14.26)

C-01 (2) - Continuation Sheet - Application and Certification for Payment (Rev 100120)

CONTINUATION SHEET

APPLICATION AND CERTIFICATION FOR PAYMENT

Containing Contractor's signed certification is attached APPLICATION #:

APPLICATION DATE:

PERIOD TO:

PROJECT #

A B C D E F G H I

ITE

M #

DESCRIPTION OF WORK QTY UNIT SCHEDULED

VALUE

(original base bid value)

WORK COMPLETED MATERIALS TOTAL

COMPLETED % BALANCE RETAINAGE

FROM

PREVIOUS

THIS PERIOD PRESENTLY

STORED

AND STORED (G / C) TO FINISH (IF VARIABLE

RATE)

APPLICATION NOT IN D OR E TO DATE (C - G)

(D + E) (D+E+F)

GRAND TOTALS

C-01 (2) - Continuation Sheet - Application and Certification for Payment (Rev 100120)

CHANGE ORDER

CONSTRUCTION PROJECTS

CONTRACTOR: Date:

Contract No.: Project Name:

Change Order No.: Work Order No.: (if applicable)

Original Contract / Work Order Amount: $

Amount prior to this Change Order, if different: $

Change Order Amount: Increase Decrease No Change $

Revised Contract / Work Order Amount including this Change Order: $

Change Order Time:

Increase

Decrease

No Change Days

Date of Substantial Completion through this Change Order:

Date of Final Completion through this Change Order:

Waiver: This Change Order constitutes full and mutual accord and satisfaction for the adjustment of Contract / Work Order Price and Time as a result of increases or decreases in costs and time of performance caused directly and indirectly from the change. Acceptance of this Waiver constitutes an agreement between the County and Contractor that the Change Order represents an equitable adjustment to the Agreement and that Contractor will waive all rights to file a contract claim of any nature on this Change Order. Execution of this Change Order constitutes Contractor’s acceptance and satisfaction that it is entitled to no more costs or time, direct, indirect, impact, etc., pursuant to this Change Order.

Acknowledgements: The aforementioned change, and work affected thereby, is subject to all provisions of the original Agreement not specifically changed by this Change Order; and it is expressly understood and agreed by the County and the Contractor that the approval of this Change Order will have no effect on the original Agreement other than matters expressly provided herein.

This Change Order does or does not involve changes to the design of the project, which would require the approval and signature of the Architect or Engineer of Record and County Project Manager.

County Project Manager: Architect / Engineer of Record: Contractor:

Name:

Address:

Sign:

Date:

PURCHASING AND CONTRACTS DIVISION:

Signature:

Procurement Administrator

As authorized by Section 3.554, Seminole County Administrative Code

WITNESS:

Date

WITNESS:

For Board approved Items: Meeting Date: Item #

C-02 - CHANGE ORDER FORM (Rev 100120)

Seminole County Board of County Commissioners

SHOP DRAWING SUBMITTALS

Date: Submittal #:

ENGINEER OF RECORD: CONTRACTOR:

Attention:

Project Manager

Project Name:

Contract No.: CIP# Contractor:

Item No. Copies Description Previous

Submission No.

Specification

Section(s) Plan

Sheet No.

Contractor’s Authorized Representative:

TO BE COMPLETED BY ENGINEER OF RECORD:

Item No.

Copies

Resubmit

Yes No

Comments

Engineer of Record: Date:

C-03 - Shop Drawing Submittal (Rev 100120)

AUTHORIZED FIELD CHANGE (AFC)

FIELD ORDER NO.:

AGREEMENT TITLE:

CONTRACT NO.:

CIP #:

CONTRACTOR:

ARCHITECT/ENGINEER:

AGREEMENT DATE:

CONTRACT DAY: OF

Note: An AFC is not an instrument that amends the Contract Documents. This AFC issued by ENGINEER to CONTRACTOR authorizes minor variations in the Work and not a change in the Work. An AFC does not entitle CONTRACTOR to any adjustment in Contract Price or Contract Time. FINAL AS-BUILT PLANS WILL REFLECT

AFC.

I. Minor Variations Authorized:

II. Justification

III. Acknowledgements: Mutually agreed to by the CONTRACTOR and the COUNTY.

This AFC authorized by:

Includes attachments:

ARCHITECT/ENGINEER

By:

Receipt of this AFC:

Acknowledged By:

CONTRACTOR

By:

C-04 - Authorized Field Change (AFC) (Rev. 100120)

2 Pages Form

C-05 - CERTIFICATE OF SUBSTANTIAL COMPLETION (Rev 100120)

CERTIFICATE OF SUBSTANTIAL COMPLETION

Construction Projects

Contractor: Date:

Master Agreement (if applicable):

CIP No.:

This Certificate of Substantial Completion applies to all work under the Contract Documents or the following specified parts thereof:

To: (Print) Architect/Engineer of Record

Contractor

The work to which this Certificate applies has been inspected by authorized representatives of CONTRACTOR, and ARCHITECT/ENGINEER, and that Work is hereby declared to be substantially completed in accordance with the Contract Documents on:

Date of Substantial Completion

A list of items to be completed or corrected is attached hereto. This list may not be all-inclusive, and the failure to include an item in it does not alter the responsibility of CONTRACTOR to complete and warrant all the Work in accordance with the Contract Documents. All items on the list shall be completed or corrected by CONTRACTOR within calendar days of the above date of Substantial Completion.

C-05 - CERTIFICATE OF SUBSTANTIAL COMPLETION (Rev 100120)

This Certificate does not constitute an acceptance of Work not in accordance with the Contract Documents nor is it a release of CONTRACTOR’s obligations to complete the Work in accordance with the Contract Documents, including “As-Built” drawings.

Executed by ARCHITECT/ENGINEER on the day of , 20

Print Name

Signature

Accepted by CONTRACTOR on the day of , 20

Executed by County’s PROJECT MANAGER on the day of , 20

PROJECT MANAGER:

C-06 - CERTIFICATE OF FINAL COMPLETION (Rev 100120)

CERTIFICATE OF FINAL COMPLETION

Construction Projects

Contractor: Date:

Master Agreement (if applicable):

This Certificate of Final Completion applies to all work under the Contract Documents.

Architect/Engineer of Record

Contractor

To: Seminole County Board of County Commissioners or Designee

The Work to which this Certificate applies has been inspected on (date) by authorized representatives of CONTRACTOR, and ARCHITECT/ENGINEER, and that Work is hereby declared to be finally completed in accordance with the Contract Documents on:

Date of Final Completion

C-06 - CERTIFICATE OF FINAL COMPLETION (Rev 100120)

This Final Completion Certificate constitutes an acceptance of Work excepting latent defects, warranty work, maintenance, and other post Final Completion obligations of the CONTRACTOR under the Contract Documents.

Executed by ARCHITECT/ENGINEER on the day of , 20

Accepted by CONTRACTOR on the day of , 20

Accepted by SEMINOLE COUNTY on the day of , 20

WITNESSES: BOARD OF COUNTY COMMISSIONERS

SEMINOLE COUNTY, FLORIDA

Procurement Administrator

As authorized by Section 3.554, Seminole County Administrative Code

Signature of Notary Public – State of Florida

Print, Type, Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced:

C-07 - CONTRACTOR’S RELEASE (Rev 100120)

CONTRACTOR’S RELEASE

This Release must be submitted simultaneously with the Contractor’s request for Final Payment and Subcontractor Affidavits.

Agreement Title: County Contract No.:

Construction Contract # OR Master Services Agreement # & Work Order #

Contractor: CIP No.:

BEFORE ME, the undersigned authority in said County and State, appeared (Name of Affiant) who, being duly sworn and personally know to me, deposes and says that he/she is (Title of Affiant) of (Full Legal Company Name), a company and/or corporation authorized to do business under the laws of Florida, which is the CONTRACTOR on (Agreement Title), located in Seminole County, Florida, dated the day of , 20 , that the deponent is duly authorized to make this affidavit by resolution of the Board of Directors of said company and/or corporation; that deponent knows of their own knowledge that said Agreement has been complied with in every particular by said CONTRACTOR and that all parts of the Work have been approved by the COUNTY’s Architect/Engineer; that there are no bills remaining unpaid for labor, Materials, or otherwise, in connection with said Agreement and Word, and that there are no suits pending against the undersigned as CONTRACTOR or anyone in connection with the Work done and Materials furnished or otherwise under this Agreement.

Affiant further says that the final estimate in the amount of $ which has been submitted to the COUNTY simultaneously with the making of this affidavit constitutes all claims and demands against the COUNTY on account of said Agreement or otherwise, and that acceptance of the sum specified in said final estimate in the amount of $ will operate as a full and final release and discharge of the COUNTY from any further claims, demands or compensation by CONTRACTOR under the above Agreement.

Deponent further agrees that all guarantees under this Agreement shall start and be in full force from the date of this release as spelled out in the Contract Documents.

Affiant

State of Florida County of

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this __ day of , 20 , by .

(Name of Affiant)

Print, Type, Stamp Commissioned Name of Notary Public

Produced Identification Personally Known OR

C-08 - CONTRACTOR’S WAIVER OF PARTIAL LIEN (Rev 100120)

CONTRACTOR’S WAIVER OF LIEN (Partial)

Copy of Waiver to be submitted with Each Pay Request

From:

Full Legal Name of Contractor

To: Seminole County Board of County Commissioners

Pursuant to the Contract, identified above, entered into on the day of , 20 , between the Contractor and Seminole County for the following project: .

CONTRACTOR CERTIFIES THAT:

1. All Work covered by Application For Payment No: has been performed in accordance with the terms of the

Contract Documents;

2. The materialmen, subcontractors, mechanics, and laborers have been paid from previous payments received from the County on account of Work performed;

3. All Material and Equipment obligations of the Contractor have been paid from previous payments received from the County on account of Work performed; and

4. All just and lawful claims of the Contractor arising out of the performance of the Work covered by this Application for Payment have been paid and satisfied.

IN WITNESS WHEREOF, the undersigned has signed and sealed this instrument this day of , 20 .

Witness:

Signature – Contractor’s Representative

Printed Name & Title

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this day of , 20 , by .

Name of Person making statement

C-09 - SUB-CONTRACTOR’S WAIVER OF PARTIAL LIEN (Rev 100120)

SUB-CONTRACTOR’S WAIVER OF LIEN (Partial)

Copy of Waiver to be submitted with Each Pay Request

From:

Full Legal Name of Sub-Contractor

To: Seminole County Board of County Commissioners

Pursuant to the Contract, identified above, entered into on the day of , 20 , between the Contractor and Seminole County for the following project: .

SUB-CONTRACTOR CERTIFIES THAT:

1. The materialmen, subcontractors, mechanics, and laborers have been paid from previous payments received from the County on account of Work performed;

2. All Material and Equipment obligations of the Contractor have been paid from previous payments received from the County on account of Work performed; and

3. All just and lawful claims of the Contractor arising out of the performance of the Work covered by this Application for Payment have been paid and satisfied.

Signature – Sub-Contractor’s Representative

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this

Print, Type, Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification

C-10 - CONTRACTOR’S WAIVER OF FINAL AND COMPLETE LIEN (Rev 100120)

CONTRACTOR’S WAIVER OF LIEN (Final and Complete)

Copy of Waiver to be submitted with Final Pay Request

(Affiant), being duly sworn according to law, deposes and states that he/she is the (Title) of (Full Legal Name of Contractor), Contractor in a Contract entered into between the Contractor and Seminole County for the (Agreement Title) and that he is authorized to and does make this affidavit on behalf of the Contractor.

THE AFFIANT FURTHER DEPOSES AND STATES THAT:

1. All Work has been performed in accordance with the terms of the Contract Documents, the Contractor alone has made all subcontracts, and the Contractor and his subcontractors have purchased all materials and fixtures and employed all labor in the performance of the Work.

2. All laborers, materialmen, mechanics, manufacturers and subcontractors who have furnished any one or all of the following: services, labor, fixtures, or materials have been satisfied and paid in full for the Work performed, and for materials, fixtures, and/or services supplied, and that the Contractor is not indebted to any person or firm in connection with the Work in any amount whatsoever.

3. There are no outstanding claims of any nature, contractual or otherwise, or for any personal injury, death or property damage, arising from or associated with the performance of the Work that might be the basis of any claim, suit, lien or demand that could be asserted against either the County or the Contractor.

4. All Bonds and Insurance policies required by the Contract are presently in effect and shall not be permitted to expire within the time periods stated in the Contract Documents.

5. This affidavit is made for the purpose of inducing the County to make Final Payment, and acceptance of such Final Payment by the Contractor shall release the County from any further liability under the Contract Documents.

Signature – Contractor’s Representative

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this

Print, Type, Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification

C-11 - SUBCONTRACTOR’S WAIVER AND RELEASE OF LIEN (Rev 100120)

SUB-CONTRACTOR’S WAIVER AND RELEASE OF LIEN UPON FINAL PAYMENT

Copy of Waiver to be submitted with Contractor’s Final Pay Request

State of: County of:

(Affiant), being duly sworn according to law, deposes and states that he/she is the (Title) of (Full Legal Name of Subcontractor), Subcontractor/Vendor/Lienor to the above Contractor under Contract with Seminole County for the (Agreement Title) and that he is authorized to and does make this affidavit on behalf of the Subcontractor.

The undersigned, in consideration of the final payment in the amount of $ , hereby waives its lien and right to claim a lien for labor, services, or materials furnished to (Contractor) on the above listed project to the following described property:

Property Address:

Tax Parcel Number:

Legal Description:

IN WITNESS WHEREOF, the undersigned has signed this instrument this day of , 20 .

Signature of Subcontractor’s Representative Title

COUNTY OF:

The Foregoing instrument was acknowledged before me by means of □ physical presence OR □ online notarization, on this day of , 20 , by (Name of Affiant), who is personally known to me or who has produced as identification.

Printed/Typed/Stamped Commissioned Name of Notary Public

Title or Rank

Serial Number (if any)

C-12 - CONSENT OF SURETY TO FINAL PAYMENT (Rev 100120)

CONSENT OF SURETY TO FINAL PAYMENT

We, (Name of Surety), having heretofore executed Performance and Payment Bonds for the above named Contractor covering the Project referenced above in the sum of Dollars ($ ) hereby agree that the County may make full payment of the final estimate, including the retained percentage, to said Contractor. The Surety concurs that full payment to the Contractor is appropriate and the Surety expressly releases the County from all liability to Surety resulting from full payment to the Contractor.

It is fully understood that the granting of the right to the County to make payment of the final estimate to the Contractor and/or his assigns shall in no way relieve this Surety of its obligations under its bonds as set forth in the Contract Documents and Bonds pertaining to the above referenced Project. By execution of this Consent, Surety specifically acknowledges that, in the event it is discovered that the Contractor has failed to pay any subcontractors under this Project, the Surety will make such payments as are due, either in whole or in part, and hold the County harmless therefrom.

IN WITNESS WHEREOF, (Name of Surety) has caused this instrument to be executed on behalf of its and its duly authorized attorney-in-fact, and its corporate seal shall be affixed, on this day of , 20 .

Signature – Surety’s Representative Signature – Attorney-in-Fact *Power of Attorney must be attached if signed by Attorney-in-Fact

COUNTY OF:

The Foregoing instrument was acknowledged before me by means of □ physical presence OR □ online notarization, on this day of , 20 , by (Name of Affiant), who is personally known to me or who has produced as identification.

Printed/Typed/Stamped Commissioned Name of Notary Public

Title or Rank

Serial Number (if any)

CONSENT OF SURETY TO FINAL PAYMENT