J.17_-_Application_for_Payment..pdf

APPLICATION FOR PAYMENT PAGE ONE OF ONE PAGES

TO OWNER:District of Columbia Courts PROJECT:

PAYMENT

APPLICATION

NO: 0 Distribution to:

Capital Projects and Facilities Management Division X OWNER

616 H Street, NW Room 6th Floor PERIOD TO: 00/00/0000 X CM

Washington, DC 20001

FROM CONTRACTOR: VIA CONST. MANAGER: CPFMD NO.:

CONTRACT FOR: Construction Services

CONTRACT FOR: Low Voltage Cabling Services CONTRACT DATE:

CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been

Continuation Sheet, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Applications for Payment were made and payments received from the Owner, and that current payment shown herein is now due.

1. ORIGINAL CONTRACT SUM $ 0.00

2. Net change by Change Orders $ CONTRACTOR:

3. CONTRACT SUM TO DATE (Line 1 ± 2) $ $

4. TOTAL COMPLETED & STORED TO $ 0.00

By: Date: 00/00/0000

5. RETAINAGE:

a. 0 % of Completed Work $ 0.00 State of: County of:

Subscribed and sworn to before me this day of

b. % of Stored Material $ Notary Public:

My Commission expires:

Total Retainage (Lines 5a + 5b) $ 0.00

RECOMMENDATION FOR PAYMENT

6. TOTAL EARNED LESS RETAINAGE $ 0.00 The Quality Assurance Manager and the Construction Manager, based on on-site observations and the data

(Line 4 Less Line 5 Total) comprising the application, verify to the best of their knowledge, the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and recommend payment to the Contractor of

7. LESS PREVIOUS CERTIFICATES FOR the amount requested on Line 8.

PAYMENT (Line 6 from prior Certificate) $ 0.00 Quality Assurance By: ________________________________Date: _____________________________

8. CURRENT PAYMENT DUE $ 0.00

9. BALANCE TO FINISH, INCLUDING RETAINAGE $ 0.00

(Line 3 less Line 6) Construction Manager By: _______________________________Date: _____________________________

CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS

Total changes approved APPROVAL FOR PAYMENT in previous months by Owner

Total approved this Month District of Columbia Courts

TOTALS $0.00 $0.00

By: ______________________________Date: ____________________________ NET CHANGES by Change Order $0.00