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

party making a loan on said real esfate or insuring title thereof, any and all lien rights upon said land and improvements thereon, and on monies or other consideration due or to become due on account of labor or services, materials, fixtures or apparatus heretofore furnished prior to December 24 2012 and billed on Application for Payment Twenty-one (#21) including monies retatined throughout project. The UNDERSIGNED, respectfully warrants that the contract status set forth above is an accurate statement and no other sums are claimed, that | have not assigned my claims for payment, nor my right to perfect a lien against said property, that | have the right to execute this Partial Lien Waiver and Affidavit on Behalf of Anderson Columbia Co., Inc. as its Project Manager, that all laborers, subcontractors, and suppliers employed by me have been paid all sums previously due and will be paid all current sums due out of this payment and that none of such laborers, subcontractors, or suppliers is or will be entitled to claim against the above described real estate or the improvements thereon for labor or materials furnished to or for the account of the undersigned. Signed this 24th day of December, 2012 Subcontractor: Anderson Columbia Co., Inc. (Name Printed) Bobby Braun, Project Manager Signed and sworn to before me this 24th day of December , 2012. po ‘ TIFFANY ADAMS Notary Publici Tiffany Adams COMMISSION # ££206430 EXPIRES JUNE 10 2016 My Commission Expires: BONDED THROUGH RL INSURANCE COMPANY | cevries 4 sew 6 is = — aa oO : = es — Seer —_ : a eee Si : fe ee 3 Lee re FT SET i : fest ee if i ree ‘oo ae 4 ra pee - | = Ls oe [es carr. eet eae Ses |e fee Foe 2 i be Pela : Rees AA ee ete i Se a i ne ti TMi : = : ) ea ee ae 22 =S——= Ee a fie ‘vi Ka a H = : 4 Hee fa —— ee = : —teete iris eee : tp Te He ee Heee t ' te ere ae ae : a a. St ls a i || i te cea te fer —eee = eo 0 5 ee = oe arr ar meat . leon HZ fae eae eure Hes fo er = : {ae seer — ae otf - euro = = : i —— ls : —s === : —aE wale — tf eeean =F a ie = =e : rr aT tae t feats t ts == a hace zur t t eee i : = ce ie E mate : Le A Beer z feet ert rato ja ofr — ue ue [ira —t = : ete i | } Bee a I E a 2 i eo a ces Bice i sa} ba Te weer ae leer : ; a Ee ai : a ia ae es fee : 2 : i See ae i a 2 : e : : Ze i BY Bee : es c rt ae a i Le : : ee— eat = ze = a : i : =o are = aa eee tage poles ibs : - = E [ee os Ata cit ca : a = a s | Bearer rai ae a 0 ate aa cast vais Ea aa : oc ar a [anton BS ee = a S : : : q a : a Ee ar ne a nee [ae se : u =a OE eee - : ae He T are cis rae Dat in , = : z = a bite eee = : eee : ae : . = = : : ee ae as r ra ee a or as = ei ox [wore im [eooar mae : : ra : i : : rer ioe ei a4 = az : ee = ae, i fe zr ae Ss He ue Hee fie fe ts a 38 500 oA a d Her ihe a con = : = = : a cE [ster ae me —| sos eeeer— tweet te 2 feet ewe [eee eee E- 2 oa SE. | ci s eet cad CT ae BT a gsi : : fr Se } oa eo : = a : : : | Seu ae weave [oon Pa “wae roromn re ee ee ee [= Fe [ssc] anton | ia [| a | —_— af T oxwame Toe CIDE ao a 37 as 2085 vojons109 = tee — = were aa i i = 7 7 z = = =| ae + ] sr i ee a aT a aa ATTA aT a a ‘Diva Hua via) —| “wera Towa arm SD eae | TR] RTT Te 1007 pew as ve 5 AVCON, INC. ENGINEERS & PLANNERS Pay Application No. 21 funding breakout: 320 Bayshore Drive, Suite A Niceville, Fl 32578 Phone: (850) 678-0050 Fax: (850) 678-0040 www.avconinc.com Per direction from Okaloosa County Airports, 44% of the construction is assumed to be AIP-eligible. A summary of the funding breakout for Pay Application No. 21 is as follows: FAA: 95% of AIP eligible cost. See Pay Application AIP Funding Summary = $43,902.85 FDOT: 54.54% of non AIP-eligible costs and 3.0% of AIP-eligible costs = $32,082.15 + $1,386.41 = $33,468.56 County: 45.45% of non AIP-eligible costs and 2.0% of AIP-eligible costs = $26,735.07 + $924.27 = $27,659.34 (Dud CIVIL & STRUCTURAL ENGINEERING @™ AIRPORT & AVIATION CONSULTING ® TRANSPORTATION DESIGN & PLANNING Date 10/5/2912 EEO Officer (Title) I, Janice Johns (Name of Signatory Party) do hereby state: (1) That | pay or supervise the Payment of the persons employed by ANDERSON COLUMBIA CO., INC. (Contractor or Subcontractor) on the Job: 6120+ TAXIWAY A,BOB SIKES AIRPORT, ; (b) WHERE FRINGE BENEFITS ARE PAID IN CASH f\ Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the Payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below. (c) EXCEPTIONS EXCEPTION (CRAFT) EXPLANATION (CTF TB5ZABHakesUNcIG-O22-20T0 that during the payroll period commencing on the 16 September 2012 and ending the ___ 22 day of 2012 , all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said ANDERSON COLUMBIA CO., INC. (Contractor or Subcontractor) day of September from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U. S. C. 3145), and described below: See attached payroll for a list of deductions (2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic Conform with the work he performed, (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency tecognized by the Bureau of Apprenticeship and Training, United States Department of Labor, of if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor. (4) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS O- In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced Payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate Programs for the benefit of such employees, except as noted in Section 4(c) below. REMARKS: Janice Johns TURE / EEO Officer VEAL: Lf NAME AND TITLE ( THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS/AUAy SUBJECT THE] CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. 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