Okaloosa County BOCC — October 20, 2015 — Floridian final pymt

CONTRACT/LEASE PAYMENT APPROVAL FORM COMPLETE AND FORWARD TO THE NEXT DEPARTMENT COMPLETED BY DEPARTMENT paTe: 10/05/2015 VENDOR NAME: Floridian Construction & Development yenpor# 014055 CONTRACT/LEASE#: C15-2299-TDD TASK COUNTY/FEMA VENDOR BUDGET INVOICE # ORDER # PROJECT # DEPARTMENT #| ACCOUNT # AMOUNT:S (If Applicable) (If Applicable) Application No. 2 1173 562790 $ 15,447.50 TOTAL $ 15,447.50 APPROVED FOR PROGRESS PAYMENT (please sign, as applicable and date CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: DATE: COUNTY SUPERVISOR/PROJECT MANAGER: / M DATE: /J/W)/ DEPARTMENT DIRECTOR: WM,—DATE: A pZ 9 Z - &‘/CONTRACTS & GRANT MANAGER: DATE: b COUNTY ADMINISTRATOR: DATE: (Payments~$§25,000.) I = FINAL PAYMENT FINAL PAYMENT YESNOD (If "Yes", forward to Purchasing Services Coordinator for Close-Out) DATE: l@l/ |2.Il = PURCHASING DIRECTOR: % A,j/l@?aé Zan ledorak (Per Initial Agreement) %{ DATE: [OS/T—,5 CONTRACTS & GRANTS MANAGER: <77 (All Contracts) DATE: /%f/,//{ COUNTY ADMINISTRATOR APPROVAL: / (Per Initial Agreement) DATE: BOARD APPROVAL: (Per Initial Agreement) COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY FISCAL YEAR: DATE RECEIVED: REVIEWD BY: APPLICATION AND CERTIFICATION FOR PAYMENT AI4 DOCUMENT G702 PAGE ONE OF PAGES TO OWNER Okaloosa County Tourist Develc PROJECT: Okaloosa Welcome Center APPLICATION NO: 2 Distribution to: Application is made for payment, as shown below, in connection with the Contract. completed in accordance with the Contract Documents, that all amounts have bea@aidgby#FF 61159 o <« 1540 Miracle Strip Parkway SE X _|OWNER Ft. Walton Beach, FL 32548 ARCHITECT PERIOD TO: September 21, 2015 CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: Tourist Development Council Floridian Construction & Development Co., Inc. P.O. Box 2412 PROJECT NOS: Santa Rosa Beach, FL 32459 \}a‘\\“{f{“’”"'S"’iln;,,,[ CONTRACT FOR: CONTRACT DATE: \\‘\?\-.,‘('5?’435.04/& % CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor crtifies tht o the best ofthe Contractors knowledg, /& &~ P65 %30 % information and belief the Work covered by this Application for Payment has begn ; g E S Continuation Sheet, AIA Document G703, is attached. the Contractor for Work for which previous Certificates for Payment were issued% L3, 8 I p y 3"; " 2nge d‘\‘w > & payments received from the Owner, and that current payment shown herein is novi’d,’@;{;-,_“ab;,.-c UneeS o - & s « . %//‘(:'&1/ T conTRACTOR: F o) lc) \ane Cmé‘i?‘(/&")'/u Joce ?’ W’”m’" Ne 1. ORIGINAL CONTRACT SUM $ 55,750.00 2. Net change by Change Orders $ 8,189.00 3. CONTRACT SUM TO DATE (Line 1 £ 2) $ 63,939.00 - 4. TOTAL COMPLETED & STORED TO $ 63,939.00 DATE (Column G on G703) By: A/%%«/ Date: % 0 j 2.0 / S 5. RETAINAGE: ) / / a. % of Completed Work $ 0 State of: a'/ orsdo— County of: Qf(a_équ,g (Column D + E on G703) Subscribed and swormyto before me this o T day,of\s:goo.a,._.h../ Q2 91s b. % of Stored Material $ 0 Notary Public: ,Q._,u_-_:b L Lo (Column F on G703) My Commission expires: _ Total Retainage (Lines 5a + 5b or /0 3 -2/ -7 Total in Column I of G703) $ 0.00 6. TOTAL EARNED LESS RETAINAGE $ 63,939.00 In accordance with the Contract Documents, based on on-site observations and the data (Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated, PAYMENT (Line 6 from prior Certificate) $ 48.,491.50 the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE $ 15.447.50 is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE $ 0.00 (Line 3 less Line 6) AMOUNT CERTIFIED........... $ CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified differs from the amount applied. Initial all figures on this Total changes approved Application and onthe Continuatio