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• <br />Application For Payment - continued <br />Total Contract Amount: $ 373,094.40 Total Amount Earned $ <br />Material Suitably Stored on Site, Not Incorporated into Work $ <br />Contract Change Order No. /, aJ 3 Percent Complete /0020 $ ? 657, P/ <br />Contract Change Order No. --5//, 5j Percent Complete /oo '9 $ T 3, /6 Z4/3 <br />Contract Change Order No. Percent Complete <br />3ci ` Q 59 <br />Contractor's Affidavit <br />GROSS AMOUNT DUE $ <br />LESS 6 % RETAINAGE $ <br />AMOUNT DUE TO DATE $ 1-41-4q ` , <br />LESS PREVIOUS APPLICATION $ -a , I' q 2 <br />AMOUNT DUE THIS APPLICATION $ ? (--) , c.) <br />The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments <br />received from the Owner on account of work performed under the contract referred to above have been applied <br />by the undersigned to discharge in full all obligations of the undersigned incurred in connection with work covered <br />by prior Applications for Payment under said contract, and (2) all materials and equipment incorporated in said <br />Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, <br />security interests and encumbrances. <br />Dated i) <br />c1/900 Central Landscaping Inc. <br />• By: <br />• <br />COUNTY OF <br />STATE OF ) SS <br />Before me on this day of <br />19 personally appeared <br />known to me, who being duly sworn, did depose and say that he is the <br />of the Contractor mentioned above; that he executed the above Application for <br />(Office) <br />Payment and Affidavit on behalf of said Contractor; and that all of the statements contained therein are true, <br />correct and complete. <br />tractor) <br />Name'nd Title) <br />My Commission Expires: <br />(Notary Public) <br />The undersigned has checked the Contractor's Application for Payment shown above. Apart of this Application <br />is the Contractor's Affidavit stating that all previous payments to him under this Contract have been applied by him <br />to discharge in full all of his obligations in connection with the work covered by all prior Applications for Payment. <br />In accordance with the Contract, the undersigned approves payment to the Contractor of the Amount Due. <br />Date <br />-3, oc) <br />Page 4 of 4 <br />By <br />SHORT ELLI <br />TT HENDRICKSON INC. <br />LINOL 9808.01 <br />