Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- South Cross Bayou Replacement of Generator Controls and Switchgear (GEN2) (PID 004906A) - STEP 1
- Solicitation number
- 26-0256-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Sample Application for Payment form used by Pinellas County Department in Florida for contractor payment processing related to construction and engineering projects. The form serves as a standardized template for contractors to submit payment requests during project execution. It accommodates change order tracking, allowing contractors to document any approved additions or deductions to the original agreement amount. The application requires documentation of the total earned amount, retainage percentages, previous payments, and the current payment due, with approval signatures from both the consultant or design professional and the Pinellas County Department's Director and Engineering Project Manager.
The form includes a lien waiver provision in which the contractor certifies that payment is requested in accordance with the contract terms and that previous payments have been used for legitimate project obligations. Upon receiving payment, the contractor releases Pinellas County Public Works and waives all claims, demands, damages, and expenses against the Board of County Commissioners for both the contractor and its subcontractors, materialmen, successors, and assigns related to the agreement performance during the specified payment period. This payment application directly supports the South Cross Bayou Replacement of Generator Controls and Switchgear project (PID 004906A) at the Pinellas County South Cross Bayou Advanced Water Reclamation Facility, which involves removal and replacement of circuit breakers, switchgear modifications, and generator control cabinet installations.
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Text version
APPENDIX 3 - SAMPLE APPLICATION FOR PAYMENT
APPENDIX 3 – SAMPLE APPLICATION FOR PAYMENT
APPLICATION AND CERTIFICATE FOR PAYMENT
From (Contractor Name) Pinellas County Department
Payment Application Number Purchase Order Number
Payment Period From:
to
CHANGE ORDER SUMMARY PAYMENT SUMMARY
Change Order #
Date Approved
Additions Deductions Original Agreement Amount $
Retainage __________ %
Total Earned Less Retainage $
Less Previous Payments $
TOTAL
NET CHANGE Current Payment Due $
I certify that the payment requested is in APPLICATION FOR PAYMENT APPROVED BY:
accordance with the terms of the agreement dated _____________ and that previous Consultant or Design Professional/Engineer of Record payments have been used to pay obligations for materials supplied and work performed in conjunction with this project. In accordance
Pinellas County ________ (Dept) Engineering Project Manager with the contract documents and in consideration of _____________ ____ paid.
___________________ (“Contractor”) releases
Pinellas County Public Works and waives for itself and its subcontractors, materialmen, successors, and assigns, all claims demands, damages, costs and Director of ___________________ (Dept) expenses, whether in contract or in tort, against the Board of County Commissioners of Pinellas County, Florida, Ex Officio the governing Board of the Pinellas County (“County”) relating in any way to the performance of the agreement between contractors and owner, dated for the period from _________________ to
Contractor Date
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