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SUB FINAL PAY APPLICATION / RELEASE

MAIL TO : Angeles Contractor, Inc. (Attention: A/P)
8461 Commonwealth Avenue, Buena Park, CA 90621
SUBCONTRACTOR NAME :
SUB MAILING ADDRESS :

PROJECT NAME : ACI PROJECT NO. :
PERIOD FROM : TO :

STATEMENT OF CONTRACT ACCOUNT
Item 1 Original Contract Amount $
Item 2 Approved Change Order Amount (SCA Received) $
Item 3 Adjusted Contract Amount (item 1 plus item 2) $
Item 4 Value Of Work Completed To Date (Attach SOV Approved) $
Item 5 Less Retention (10% of item 4) $
Item 6 Total Less Retention (item 4 minus item 5) $
Item 7 Less Previous Certificates For Payment (item 6 from last pay app) $
Item 8 Amount Due This Request (item 6 minus item 7) $
Item 9 Balance To Finish, Including Retainage (item 3 minus item 6) $

CERTIFICATE OF SUBCONTRACTOR
I hereby certify that the work performed and the materials supplied to date, as shown on the above, represent the actual value of accomplishment under the
terms of the contract (and all authorized changes thereto) between the undersigned and relating to the above referenced project
SIGNATURE OF SUBCONTRACTOR
NAME & TITLE

CONDITIONAL WAIVER AND RELEASE ON FINAL PAYMENT AFFIDAVIT OF COMPLIANCE WITH CALIFORNIA PREVAILING
California Civil Code Section 8136 WAGE LAW, CALIFORNIA LABOR CODE SECTIONS 1720-1815
NOTICE: THIS DOCUMENT WAIVES THE CLAIMANT'S LIEN,
STOP PAYMENT NOTICE, AND PAYMENT BOND RIGHTS The undersigned, being duly sworn, states that it is a Subcontractor for
EFFECTIVE ON RECEIPT OF PAYMENT. A PERSON SHOULD Angeles Contractor, Inc. on the public project listed below, and has
NOT RELY ON THIS DOCUMENT UNLESS SATISFIED THAT THE complied with the provisions of the Cal. Labor Code Sections 1720-1815,
CLAIMANT HAS RECEIVED PAYMENT. and has paid all employees the specified general prevailing rate of per
diem wages to its employees, and any amounts due pursuant to Cal.
Identifying Information Labor Code 1813. Also, the Subcontractor has employed the required
Name of Claimant: number of apprentices on this project as required. In addition, the
undersigned makes this sworn statement pursuant to Cal. Labor Code
Name of Customer: Angeles Contractor, Inc. 1775(b)(4) and 1777.7(d)(4).
Job Location:
Owner: The undersigned has also reviewed the payroll practices of each of
Conditional Waiver and Release Subcontractor's lower-tiered subcontractors on this project. Each of
subcontractor's lower-tiered subcontractors has paid the specified
This document waives and releases lien, stop payment notice, contract prevailing rate of wages to its employees, has paid any amount due
rights, and payment bond rights the claimant has for labor and service such employees under Cal. Labor Code 1813, has employed the
provided, and equipment and material delivered, to the customer on this job. required number of apprentices on this project, and has provided
Rights based upon labor or service provided, or equipment or material subcontractor with an affidavit that complies with Cal.
delivered, pursuant to a written change order that has been fully executed by Labor Code 1775(b)(4) and 1777.7(d)(4).
the parties prior to the date that this document is signed by the claimant, are
waived and released by this document, unless listed as an Exception below.
This document is effective only on the claimant's receipt of payment from the Name of Project: __________________________________
financial institution on which the following check is drawn: Address of Project:__________________________________
Maker of Check: Angeles Contractor, Inc.
Amount of Check: $ I declare under penalty of perjury under the laws of the State of California
Check Payable to: that the foregoing is true and correct.
Exceptions Executed this ______________ day of _________________, 20___
This document does not affect any of the following: _____________________________________________, California.
Disputed claims for extras in the amount of: $
_____________________________________ (Subcontractor Name)
Signature
Claimant's Signature: _____________________________________(Authorized Signature)
Claimant's Title _______________________________________ (Name & Title)
Date of Signature:

REV: 1.0.5 10/11/2012