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Okaloosa County BOCC — December 18, 2012 — Contractor's Application for Payment — reading text
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CONTRACTOR’S APPLICATION FOR PAYMENT
APPLICATION NO. 4
TO OWNER: Okaloosa County Board of County Commissioners
Attn: Larry Willams
Okaloosa County Extension Office
5479 Old Bethel Road
Crestview, Florida 32536
FROM CONTRACTOR: Mike Moulton Construction, Inc.
License # BK 116583
8918S. Ferdon Blvd.
Crestview. Florida 32536
(850) 305-6466
PERIOD TO:
Original Contract Sum $653,900.00
Change Orders $ 12,850.00
Contract Sum To Date $666,750.00
Total Completed To Date Draw 4 100%
Less Previous Payments $ 588.510.00
Current Payment Due $_ 78,240.00
Balance to Finish $- 0
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 payments have been paid by the Contractor for Work completed and that
current payment shown herein ts now due.
CONTRACTOR: Mike Moultgn Construction, Inc.
Date: iA Hf LEY 1 -
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State of: Florida County of: Okalogss
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My Commission expires:
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Notary Public:
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2 EXPIRES March 27, 2016
(407) 398-0183 ioridaNotaryService.com