Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
Sanitary Sewer CIPP Rehabilitation – Various Locations (PID 001933DEF)
Solicitation number
24-0206-ITB-C
Issued by
Pinellas County, Clewiston City, Florida

About this file

Written by GovTribe AI ·

This document is a Sample Application for Payment form for Pinellas County, Florida, designed for contractors to request payment for work completed on a project. The form provides a standardized template for documenting change orders, payment summaries, and contractual releases, with sections for the contractor to certify that previous payments have been used to pay for materials and work performed. The form includes spaces for tracking original agreement amounts, retainage percentages, total earned amounts, previous payments, and current payment due.

The application serves as both a payment request and a legal release, where the contractor waives claims against Pinellas County for the specified payment period. The document requires approval signatures from multiple parties, including a consultant or design professional, a Pinellas County Engineering Project Manager, and the department director. While this specific form is a sample template, it is directly linked to the Sanitary Sewer CIPP Rehabilitation project (PID 001933DEF), which involves cleaning, videoing, and installing cured-in-place pipe in existing gravity sewer mains to reduce infiltration and extend the pipe system's life by at least fifty years.

View the file

Other files

File Type Posted
001933DEF_Maps_and_Work_Plans_final_updated_012624.pdf PDF
Pricing_Proposal_ITB24-0206(reference_only-updated).pdf PDF
Sanitary_Sewer_CIPP_Rehabilitation_–_Various_Locations_(PID_001933DEF).pdf PDF
Affdavit_of_Release_and_Guarantee24-0206-ITB-C.pdf PDF
Agreement-24-0206.pdf PDF
SBE_Compliance_Form.pdf PDF
Sample_Performance_and_Payment_Bonds.pdf PDF
QUALIFICATION_SUBMITTAL_FORM.pdf PDF
OpenGov_Fillable-_Final.pdf PDF
Bid_Submittal_Form-JOC.pdf PDF
Technical_Specifications.pdf PDF
Airport_Security_Program.pdf PDF
E-Verify_Affidavit.pdf PDF
Florida_Trench_Safety_Form.pdf PDF
Sample_Change_Order.pdf PDF
Show all 15

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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

File details come from the government source that posted it. Updated .