Application for Payment No. 4
'"~'
CER'rIFICATION OF CONTRACTOR
f \i r
j~qR9
According to the best of my kno\vledge and belief, I certify that .all items and amounts
shown on Application for Payment No. 4 are correct, that all work has been
performed and/or materials supplied in full accordance with the terms and conditions of
this Contract, dated 1-17 -' 19~ between
~bnroe County, Florida
(Owner)
and
Continental Construction Canpany, Inc.
(Contractor)
I further certify that all just and lawful bills against the undersigned and his
subcontractors and suppliers for labor, material and equipment employed in the
performance of this Contract have been paid in full accordance with their terms and
conditions; that all taxes irnposed by Chapter 212, Florida Statutes (Sales and Use Tax
Act), as amended, have been paid and discharged; and that there are no Vendor's,
Mechanic's or other Liens or rights to liens or conditional sales contracts which should be
satisfied or discharged before such payment is made. C~ental con,b(u..::E:on Carpany, Inc.
Date: 2-28-89 Contractor: ~ ~ U~ Sec.-Treas.
STATE OF Tennessee)
55
COUNTY OF Shelby)
Personally appeared before me this 28th day of
February
, 19~
Rodney v.7ai ts
known (or-mftde knoYffl) to me to be the
SecretaJ:y-Treasurer
(Owner) (Partner) (Corporate Officer - Give TitleY-
of Continental Construction Corrpany, Inc. Contractor(s),
who subscribed and swore to the above instrument in my presence.
A. ti-:- );f ~. ,
F-~. Bailey ~
Notary Public - (Type Name)
My Com mission Expires:
6-2- , 1 g:J2 .
The Contractor shall execute this Certificate and attach it to each Application For
Payment.
Page 19
22-506.70