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APPLICATION FOR PAYMENT NO. 14 (Final) <br />Original Contract Amount: $1,549,732.38 <br />Material Suitably Stored on Site, Not Incorporated into Woric <br />Change Order No. _1_ : <br />Change Order No. _2_ <br />Change Order No. <br />$27,419.41 <br />$8,503.90 <br />Total Amount Earned: $1,545,808. <br />Change Order % Complete 100% $27,419.41 <br />Change Order % Complete 100% $8,503.90 <br />Change Order % Complete <br />Gross Amount Due: $1,581,73135 <br />Less Retainage: <br />Amount Due to Date: $1,581,731.35 <br />Less Previous Applications: (S1,486,155.49) <br />Amount Due This Application: $95,575.86 <br />CONTRACTOR'S AFFIDAVIT <br />The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from <br />the Owner on account of work performed under the Contract referred heretofore have been applied by the undersigned to <br />discharge in full all obligations of the undersigned incurred in connection with work covered by prior Applications for <br />Payment under said contact (indicated below), and (2) all material and equipment incorporated in said Project or otherwise <br />listed in or covered by this Application for Payment and free and clear of all liens, claims, security interests and encumbrances. <br />Contract for Legacy at Woods Edge - Phase 3 Streetscape, Planting and Irrigation Plans <br />Jay Bros., Inc. <br />(Contractor) <br />COUNTY OF <br />STATE OF <br />) SS <br />3 -\O -0c <br />(Date) <br />(Name and 1 itle) <br />Before me on this ICJ • day of 1--i ive_ti , 20 0 of personally appeared <br />1A; eX. A S `S� , known to be, who being duly sworn did depose and say that he/she is the <br />C- p 1 of the Contractor above mentioned that he/she executed the above Application for <br />Payment and Affidavit on behalf of said Contractor and that all of the statements contained therein are true, correct, and <br />complete. <br />My commission expires: } = -DO IC1 <br />• <br />RUTH k HOGLUND <br />AVIARY rUauC AM141•TcfrA <br />14 Commission Empires 1 -31 -2011 <br />The undersigned has checked the Contractor's Application for Payment shown above. A part o ' Application is <br />the Contractor's Affidavit stating that all previous payments to him/her under this contract have been applied by him/her to <br />discharge in full all of his/her obligations in connection with the work by all prior Applications for Payment. <br />Short Elliott Hendrickson Inc. <br />(Signature) <br />Approved by <br />City of Lino Lg <br />By 4US! ! AA- I 0/4 PPR/Nu PAL, <br />(Name and Title) <br />Date ri %3/0 <br />(Signs ) (Name and Title) <br />Dar Sit /(97 <br />