Sample_Application_for_Payment.pdf

This is a Sample Application for Payment form used by Pinellas County Department in Florida for processing contractor payments on construction and renovation projects. The form serves as the official payment application and certificate mechanism between the contractor and Pinellas County, documenting payment requests for work performed and materials supplied. The application includes sections for tracking the payment application number, purchase order reference, and the specific payment period being billed. It incorporates a change order summary table that records approved modifications to the original agreement, including additions and deductions, and provides a detailed payment summary showing the original agreement amount, retainage percentage, total earned amounts, previous payments applied, and the current net payment due.

The form requires certification by the contractor that all payment requests comply with the agreement terms and that previous payments were properly applied to project obligations. It mandates approval signatures from both the Pinellas County Engineering Project Manager and the Department Director, and includes a broad release clause whereby the contractor waives all claims and demands against the Board of County Commissioners related to project performance for the payment period covered. This payment application template establishes the financial control and documentation standards for the Solid Waste Administration Building HVAC Renovation project, which involves complete replacement of building HVAC systems including two 15-ton VAV DX split systems, a 100% outside air system, new VAV terminal units, DDC controls, ductwork modifications, exhaust fans, and optional scope enhancements such as attic sealing and roof insulation upgrades.