Okaloosa County BOCC — February 21, 2017 — C16-2465-FM--3.Application & Certification for Payment

APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONEOF 2 PAGES TO OWNER: PROJECT: APPLICATION NO 1 Distribution to: Okaloosa County Purchasing Demo. Of SE Wing OWNER 5479A Old Bethal Rd Old FWB Hospital ARCHITECT Crestview, FL 32536 PERIOD TO: 1/9/17 X |CONTRACTOR FROM CONTRACTOR: VIA ARCHITECT: VIRGINIA WRECKING CO., INC. P.O.Box 2730 PROJECT NOS: RFB FM 72-16 Daphne, AL 36526 Contract C16-2465-FM CONTRACT FOR: CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, AIA Document (G703, is attached. . ORIGINAL CONTRACT SUM . Net change by Change Orders . CONTRACT SUM TO DATE (Line 1 £ 2) . TOTAL COMPLETED & STORED TO DATE (Column G on G703) 5. RETAINAGE: a, 0 % of Completed Work $ $0.00 {Column D + E on G703) b. % of Stored Material $ {Column F on G703) Total Retainage (Lines 5a + 5b or Total in Column I of G703) 6. TOTAL EARNED LESS RETAINAGE (Line 4 Less Line 5 Total) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT (Line 6 from prior Certificate) . CURRENT PAYMENT DUE 73,328.00 9. BALANCE TO FINISH, INCLUDING RETAINAGE $ 0.00 (Line 3 less Line 6) - 73,328.00 L N — CeR-c - 73,328.00 0.00 73,328.00_ @ o0 @9 9 CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS | Total changes approved in previous months by Owner Total approved this Month TOTALS $0.00 $0.00 NET CHANGES by Change Order $0.00 The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. CONTRACTOR: Virginia Wrecking Co., Inc, By Q IZEZ@AMW Date: ## 27-Jan-17 “Daniel A. Schambeat/Vice President State of: Alabama County of: Baldwin 7 Subscribed and sworn to before me this 9th day of January 2017, j;fi’ Notary Public: Sue Schambeau J My Commission expires: June 18, 2018 Y In accordance with the Contract Documents, based on on-site observations and the data comprising the application, the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. AMOUNT CERTIFIED ........... $ (Attach explanation if amount certified differs from the amount applied. Initial all figures on this Application and onthe Continuation Sheet that are changed to conform with the amount certified,) ARCHITECT: By: Date: This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. AlA DOCUMENT G702 + APPLICATION AND CERTIFICATION FOR PAYMENT - 1992 EDITION - AIA® - © 1992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 20006-5292 Users may obtain validation of this document by requesting a completed AlA Document D401 - Certification of Document's Authenticity from the Licensee. CONTINUATION SHEET AIA DOCUMENT G703 PAGE OF PAGES 2 AJA Document G702, APPLICATION AND CERTIFICATION FOR PAYMENT , containing APPLICATION NO: 1 Contractor's signed certification is attached. APPLICATION DATE: 1/9/117 In tabulations below, amounts are stated to the nearest dollar, PERIOD TO: 119117 Use Column I on Contracts where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: A B C D E F G H 1 ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL % BALANCE RETAINAGE NO. VALUE FROM PREVIOUS | THIS PERIOD PRESENTLY COMPLETED {G+C) TOFINISH |(IF VARIABLE APPLICATION STORED AND STORED €-G