HomeMy WebLinkAboutTip Top Roofing Co, Inc. -1999 08 05
TIP-TOP ROOFING CO., INC.
P 0. BOX 941959. MAITLAND. FL 32794-1959 (407) 660-2212
PA Y REQUEST: 01
DA "J."E : April 05, 1999
PROJECT: Fire Station '211
OWNER: same
TO: City of Winter Springs
1126 E. State Road 11311
Winter Springs, Florida 32708
Pay Period Endi ng : 011/02/99
Purchase Order 1116711 dated 02/25/99
Original Contract Amount:
Approved Change Orders:
$
22.590.00
$ nla
Revised Contract Amount: $ 22,590.00
Materials Stored On Site: $ nla
Complete To Date~ $ 22,590.00
Retainage I f Applicable: $ nla
Total Earned Less Retainage: $ 22.590.00
Less Previous Payments: $ nla
CURRENT PAYMENT DUE ON RECEI PT: $ 22,590.00
, ~/Full Release of Lien
The undersigned certifies that all material, labor or services for which payment is requested
have been fully paid for and the above project cannot be liened or made claie to by anyone who
has furnished aaterial, labor or services to the undersigned and the undersigned hereby releases
the Owner froa further liability for materials, labor or services furnished by the undersigned
through this pay period. The undersigned further states that all Social Security taxes,
witholding taxes, Sales and Use taxes, permits, Workers' Compensation and other insurance
prelliuas and all taxes iaposed by Chapter 212, Florida Statutes as alIended, which have occurred
in conBection with this construction project have been fully paid.
This release becomes in full force and effect upon receipt by the undersigned
the aIIOunt of: $ 22,590.00
State of Florida" County of Orange
Subscribed and sworn to before me
this 05th day of
NOTARY PUBLIC:
SUSAN N.lARSON
MDDY PublIc - state of Florida
MtCommlsslon ExJ*e5 Aug 23. 2002
ComA'llssion' CC769l1YJ
Note: This statutory fora prescribed by Section 713.20, Fl u ). Effective
October 01, 1996, a person may not required a lienor tofumish a waiver of release of lien that
is different froa the statutory form.
My Commission Expires:
/.~~-l.i T "j.:T';
CONDITIONAL
WAIVER AND RELEASE OF LIEN
UPON FINAL PAYMENT
(PAYMENT BY CHECK)
'l'he undersigned lienor, in consideration of the final payment in the amount of
$ 22,590.00 and conditioned upon payment of check number issued
to the lIndersi~ned by City Of Winter Springs in said amount, waives and
releases its lien and right to claim a lien for labor, services or materials furnished to
(cllstomer) City Of Winter Springs on the job of (owner property)
Fire Department - Station '24 , to the following described property:
Winter Springs Fire Station 124
102 N. Moss Road
Winter Springs, Florida
.;"
"-
Dated On April 05
,1999 .
Lienor's Name Tip-Top Roofing Co.., Inc.
Address P.O. Box 941959
Maitland. Florida 32194-1959
By
VP
Printed Name
NOTE: This is n stntutOl'Y form prescribed by Section 713.20, Florida Statutes
(1.9.%'). Effectiue October 1, 1996, a person may not require a lienor to furnish a
waiuer or release of lien that is different from the statutory fonn.
:cn:-v OF .W!NTER SPRINGS,
1126 E, STATE ROAD 434.
WINTER SPRINGS~ FLORIDA~708
(407) 327...1800
PAGE
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THIS NUMBER MUST APPEAR ON ALL
PACKAGES. INVOICES AND CORRESPONDENCE
'URCHASE ORDER DATE DATE REQUIRED RQUISITION NUMBER VENDOR NO. SPCL. INSTJPURPOSE
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CONFIRMATION BLANKET CONTRACT
PAYMENT TERMS
FREIGHT
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QUANTITY UNIT OF MEASURE
i JUB l'j'f) f Nt, 0'.,,]
DESCRIPTION
UNIT PRICE EXTENSIO
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fi;)OF Rf1-'AIR AS QUAOI'ED PEP, PRCJPOSAL fOF O)A..L, 'CAR.
PI'I\::H ROOF SYSTFJ!, A2PH')'v'ED ON CONSENT Jl,GENDl\U IT -f
El:':BRU,';.PY :::. IS;!~) FR(H P & l! BlJLLOJ:NG GENF..FAL FUNO
FESERJE ,
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PRU'ilDE ALLIE.:n :;',IGN!\L ::0 YH NOL WARRAN"T'Y
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WORK / PRODUCT
RECEIVE~ SPECIFIED
SIGNED: ~
PRINTNAME:.1.~~ ~~~
DATE: 1.L:.$ ~q q
t J
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T01'~J.. PfJRCH/l..5E ORDEF
AMOUNT
225;'l~'6'
2:'10
54660
2 :2 ~~ '~i2-~ (i{1
BY
\... DATE
PURCHASING (J P PETRENCSIK)
BY
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DATE
CITY MANAGER
TAX NO. 69-13-035082-54C
RECEIVING COpy
BID NO.