Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Grand Canal Maintenance Dredging Project - ARPA Funded State and local contract opportunity
- Solicitation number
- 23-1177-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, Florida, designed for contractors to request periodic payments for completed work. The form includes sections for documenting change orders, payment summaries, and a comprehensive release of claims, with spaces for various approvals from the Consultant/Design Professional, Engineering Project Manager, and Department Director. The template allows contractors to specify the payment period, original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due.
While this is a sample form and not a specific contract document, it is associated with the Grand Canal Maintenance Dredging Project, an American Rescue Plan Act (ARPA) funded initiative in Florida. The project involves dredging a 150-ft wide channel in the Grand Canal area to maintain navigation from Pass-A-Grille Inlet, with the channel to be maintained at -11.5 ft NAVD with a 1 ft over-dredge allowance. The project encompasses approximately 15.5 acres and involves removing around 13,000 cubic yards of material, which will be placed on Pass-a-Grille beach within the permitted beach template, with careful consideration to avoid impacts to seagrass beds.
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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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