Okaloosa County BOCC — December 18, 2012 — Bob Sikes Airport Taxiway A - Change Order #5, Close-out docs, Final Payment form — reading text

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Tota (Net wasesra an igi lentifier ‘emptions / Race m " 9 te Kh Group ‘otal from attache ‘oO it SS and full address required] & Gender _ | Work Classification | = Hours |PayRate) / eekly irctneree Deductions | for week on contracts Let prior to 1/19/09) 2 te) NO WORK PERFORMED s NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED NO WORK PERFORMED adler 2013 — 2 ote, SUSAN E. CHAPPELL sy Xe Notary Public - State of Florida < + My Comm. Expires Jun 11, 2015 (Notary Publiwy Nese? — Commission # EE 69486 CONTRACTORS RELEASE OF LIENS BOB SIKES AIRPORT QKSLOOSA COUNTY. TAXIWAY A REHABILITATION CONTRACTOR'S RELEASE OF LIENS s STATE OF; _ Florida | COUNTY OF: _ Columbia Before me, the undersigned Notary Public in and for the said County and State personally appeared | Bert Myers, Controller » representing the Contractor Anderson Columbia Companies, Inc » who being duly sworn according to law deposes and says that all labor, materials, and outstanding olaims and indebtedness of whatever nature arising out of the performance of the Contract with Qkaleoga Board of CC the Owner, for Bob Sikes Airport Taxiway Rehab, Contract No. , have been-paid in full and that for the final payment in the amount of § 105,030.75 , the Contractor releases and discharges the Owner and his authorized representatives from any Hens or claims or any nature because of or arising from this Contract and/or its performance, whioh it has had, hes or may have in the future. Sworn to and subscribed before me this “MRE” Bonded Though National Notary Assn My Commission Expires: 06/11/2015 __ JONE 2010 gp CONRELNS: PAGE | of | AYCON, ING. SUBCONTRACTOR’S SWORN STATEMENT TO GENERAL CONTRACTOR ON REQUESTING FINAL PAYMENT STATE OF Flozinan COUNTY OF _ES¢CAm Gia Before me, the undersigned authority, personally appeared Davio &. Cook who, being first duly sworn, on oath deposes and says: 2 Cc 1. That Gul Coasi Taree EF tere a/an lor Potton hereinafter called “Subcontractor”. (Individual/Partnership/Corporation) 2. That affiant isthe OFF «CER of Subcontractor and is authorized to make this affidavit. (Owner/Officer) 3. That Subcontractor heretofore entered into a subcontract with Anderson Columbia Company, Inc., hereinafter called “General Contractor,” under Subcontract No. 6/20! ,onthe_/¢ day of OCIOiAEL 2012 for Boie SiKES AIRPORT Taxing A REMABILITA TIOM Cestuew, EC in the amount of $292,234 3. to furnish material, labor or services for the construction of a certain building, or repairs, or alterations specifically described in said subcontract, as amended. 4. Subcontractor has fully completed all work and furnished all materials in accordance with the terms of said subcontract and all amendments thereto; that all lienors, including, but not limited to all laborers, materialmen and taxes, have been paid in full, except: (List names of lienors and amounts owed.) N/A 5. Receipt by the Subcontractor of the final payment, under the aforementioned subcontract, shall constitute a full release and discharge by the Subcontractor to the General Contractor of all claims of the Subcontractor against the General Contractor, arising out of, connected with, or resulting from performance of the obligations of the Subcontractor pursuant to said subcontract and all amendments thereto. Golé Coast Teakhic EnGiviéRs, |&© (SEAL) Subcontr ctor Dat fall em By Swoi r and subscribed before me this_/6 dayof__oc7To Ree »2ol2, / Ato Pa Lt A& eA CATHERN E. RETHERFORD Notary Publié 3 Notary Public - State of Florida My Comm. Expires Apr 10, 2014 Commission # DD 957292 SUBCONTRACTOR’S SWORN STATEMENT TO GENERAL CONTRACTOR ON REQUESTING FINAL PAYMENT STATE OF Chloride couNTY oF _ Okaloosa Before me, the undersigned authority, personally appeared Chad M. Thumetino, being first duly sworn, on oath deposes and says: | . 1. That CourVvey is/are a/an Criterion hereinafter called “Subcontractor”. (Individual/Partnership/Corporation) 2. That affiant is the a) G Cey of Subcontractor and is authorized to make this affidavit. (Owner/Officer) 3. That Subcontractor heretofore entered into a subcontract with Anderson Columbia Company, Inc., hereinafter called “General Contractor,” under Subcontract No. (fZ0(_, on the 28 _ day of £ Dtude 201! tor Hopecte # MleZ00 Vin the amount of $ 7@, 000.00%0 furnish material, labor or services for the construction of a certain building, or repairs, or alterations specifically described in said subcontract, as amended. 4. Subcontractor has fully completed all work and furnished all materials in accordance with the terms of said subcontract and all amendments thereto; that all lienors, including, but not limited to all laborers, materialmen and taxes, have been paid in full, except: (List names of lienors and amounts owed.) 5. Receipt by the Subcontractor of the final payment, under the aforementioned subcontract, shall constitute a full release and discharge by the Subcontractor to the General Contractor of all claims of the Subcontractor against the General Contractor, arising out of, connected with, or resulting from performance of the obligationsf the Subcontractor pursuant to said subcontract and all amendments thereto. // [ g Ay he a ” (SEAL) a= Subcontractor (SEAL) By Sworn to,and subscribed before me this Kk day ot Uefober. UZ. SEAL 7 ‘Notary AL hi Re, CHRISTINE M. keaton 2 MY COMMISSION # €E206659 SXPIRES June 19, 2018 FigndanotoryServica com SUBCONTRACTOR’S SWORN STATEMENT TO GENERAL CONTRACTOR ON REQUESTING FINAL PAYMENT STATE OF _ Florida COUNTY OF Escambia Before me, the undersigned authority, personally appeared Traci In gta - Ga, who, being first duly sworn, on oath deposes and says: Ine. 1. That Ingram Signalization, is/are a/an Corporation hereinafter called “Subcontractor”. (Individual/Partnership/Corporation) 2. That affiantis the officer of Subcontractor and is authorized to make this affidavit. (Owner/Officer) 3, That Subcontractor heretofore entered into a subcontract with Anderson Columbia Company, Inc., hereinafter called “General Contractor,” under Subcontract No$1201-1463y the A2th- day of April ,20.11for Bob Sikes Airport Taxiway A Rehabilitation in the amount of $580,072. 00to furnish material, labor or services for the construction of a certain building, or repairs, or alterations specifically described in said subcontract, as amended. 4. Subcontractor has fully completed all work and furnished all materials in accordance with the terms of said subcontract and all amendments thereto; that all lienors, including, but not limited to all laborers, materialmen and taxes, have been paid in full, except: (List names of lienors and amounts owed.) 5. Receipt by the Subcontractor of the final payment, under the aforementioned subcontract, shall constitute a full release and discharge by the Subcontractor to the General Contractor of all claims of the Subcontractor against the General Contractor, arising out of, connected with, or resulting from performance of the obligations of the Subcontractor pursuant to said subcontract and all amendments thereto. Ingtah Sx@nalization, Inc. (SEAL) ff iyo tractor , Ay Yt fe 1 Y, bdtnt LLY tA Juhani (SEAL) f wre f B v / Y ; f H. Sworn to and subscribed before me this_/S dayof_@ he (8 »LO/2. 7 AUDREY FARAGHER 2, NOTARY PUBLIC STATE OF FLORIDA Audet Ly Vip tae, (SEAL) Cormm# DDG91032 NotaryPublic oma mia NGEWM Exolras 5/12/2014 SUBCONTRACTOR’S SWORN STATEMENT TO GENERAL CONTRACTOR ON REQUESTING FINAL PAYMENT STATEOF ORDA COUNTY OF _ DKALAOSA Before me, the undersigned authority, personally appeared £ HEMIE oveE who, being first duly sworn, on oath deposes and says: 1. That_7Z7@ Le, Lun at Peed /are a/an lar, 0 a fror- _ hereinafter called “SubconfrActor”. (Individual/Partnership/Corporation) That affiant is the Presiden £ of Subcontractor and is authorized to make this affidavit. (Owner/Officer) That Subcontractor heretofore entered into a subcontract with Anderson Columbia Company, Inc., hereinafter called “General Contractor,” under Subcontract No fof on the day of hips hese ,20/Afor_ U Tye Dssipatns 2 CC PA vewen in the amount of SL 929.54 to furnish material, labor or services for the construction of a certain building, or repairs, or alterations specifically described in said subcontract, as amended. Subcontractor has fully completed all work and furnished all materials in accordance with the terms o/ said subcontract and all amendments thereto; that all lienors, including, but not limited to all laborers, materialmen and taxes, have been paid in full, except: (List names of lienors and amounts owed.) N/A Receipt by the Subcontractor of the final payment, under the aforementioned subcontract, shall constitute a full release and discharge by the Subcontractor to the General Contractor of all claims of the Subcontractor against the General Contractor, arising out of, connected with, or resulting from performance of the obligations of the Subcontractor pursuant to said subcontract and all amendments thereto. . Bia Lahn d Lbast- __ (SEAL) a Lede Wot rc _, breodasedey = ren By Sworn to and subscribed before me this et day of AcmRer ib (2, ESHE Lette (SEAL) BOBBY BRAUN Notary Public COMMISSION # £68923 EXPIRES MARCH 27 2015 BONDED THROUGH RL INSURANCE COMPANY. SUBCONTRACTOR’S SWORN STATEMENT TO GENERAL CONTRACTOR ON REQUESTING FINAL PAYMENT STATE OF Florida COUNTY OF Bay Before me, the undersigned authority, personally appeared Mike Swearington who,