Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Countywide Mast Arms - Group 3 (PID 004183A)
- Solicitation number
- 23-1147-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a sample Application for Payment form used by Pinellas County Department for the Countywide Mast Arms - Group 3 project (PID 004183A). The project involves replacing existing signalization with mast arms at seven intersections, including locations such as E Tarpon Ave at US 19, Lake St George Dr at Tampa Rd, and others. The project includes minor roadway improvements and ADA guideline compliance, and is federally funded through the Federal Emergency Management Administration (FEMA), with Pinellas County serving as the administering agency.
The payment application form provides a template for contractors to request payment, with sections for change order summaries, payment summaries, and certification of payment. The form includes fields for tracking the original agreement amount, retainage percentage, total earned amounts, previous payments, and current payment due. It also includes a release and waiver clause for the contractor, protecting Pinellas County from future claims related to the project. The form requires approval signatures from a consultant or design professional, the county's engineering project manager, and the department director, ensuring multiple levels of verification for each payment request.
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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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