10/09/2000 Council Packet - Laserfiche WebLink

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a • Application for Payment - continued Total Contract Amount: $1,991,329.71 Total Amount Earned $ 1,886,506.99 Material Suitabley Stored on site, Not Incorporated into Work $ Contract Change Order No. 1 Percent Complete 100% $ 19,158.91 Contract Change Order No. 2 Percent Complete 100% $ 3,207.48 Contract Change Order No. 3 Percent Complete 100% $ 1,210.12 Contract Change Order No. 4 Percent Complete 100% $ 376.33 Contract Change Order No. 5 Percent Complete 100% $ 9,569.99 GROSS AMOUNT DUE $1,920,029.82 J LESS 0% RETAINAGE; IN ESCROW ACCOUNT $ AMOUNT DUE TO DATE $ 1,920,029.82 LESS PREVIOUS APPLICATION $ 1,824,028.33 ✓ AMOUNT DUE THIS APPLICATION $ 96,001.49 Contractor's Affidavit The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from the owner on account of work performed under the contract referred to above have been applied by the undersigned to discharge in full all obligations of the undersigned incurred in connection with work covered by prior Applications for Payment under said contract, and (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances. Dated B 241 g p� COUNTY OF rSTE-se:IA -Ai S STATE OF /titl4Neson4 ) SS J i L L/ i5 et, Al Srn4.r r7ow1, (Contractor) By: i% a.K :. /j (Name d Title) Befpre me on this 24 day of A-- .G�S"r ,.*9 personally appeared Lui 4Yk.W tar,.So,,4 known to me, who being duly sworn, did depose and say that he is th e5r7w.a of the Contractor mentioned above; that he executed the above Application (office) K o Payment and Affidavit on behalf of siad Contractor; and that l of the statements contained therein are true, g n m �n g t R7 L correct and complete. My Commission Expires: 0131 /o — (Notary Public) r- > The undersigned has checked the Contractor's Application for Payment shown above. A part of this Applicatio o o m is the Contractor's Affidavit stating that all previous payments to him under this Contract have been applied by to discharge in full all of his obligations in connection with the work covered by all prior Applications for Payment. In accordance with the Contract, the undersigned approves payment to the Contractor of the Amount Due. SHORT ELLIOTT HENDERICKSON INC. Date v /zooe) By: