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Distribution to: <br />o <br />O 0 <br />w H [L <br />Z 0 <br />0 < <br />MOD( <br />APPLICATION # <br />m <br />0 <br />J <br />0 <br />0 <br />PERIOD THRU: <br />c <br />0 <br />m <br />U) <br />0 <br />00 <br />m <br />U <br />d <br />0 <br />PROJECT #s: <br />6786 Clearwater Creek Drive <br />Z Z <br />5 Q <br />tic 1- <br />gg 0 <br />az0 <br />Lino Lakes, MN 55014 <br />O <br />Lino Lakes, MN 55014 <br />ATE OF CONTRACT: <br />0 <br />co CI <br />:: T <br />�Z <br />0 CO <br />a <br />0 o <br />0 <br />H <br />ARCHITECT: <br />0 <br />m <br />3 <br />0 <br />22 <br />E <br />E <br />c . <br />La a. <br />Isanti, MN 55040 <br />0 <br />a O <br />w w <br />` ` N <br />v0- .O o <br />'O as <br />Q N 40 <br />iE o <br />y <br />M <br />Eigji• <br />0 0 o <br />aEo S. <br />0 <br />0 o Piy <br />00 o <br />j p m <br />o <br />0. <br />8 8 O <br />L V <br />o <br />gg <br />c o <br />e: o ' <br />2 <br />L 0 0 7 <br />CO 4 N . <br />8 0 0 0) 5. <br />Lo <br />0oyca <br />0 co <br />-6.2o <br />o <br />co Q. <br />-cta <br />c • > - m <br />p lO N N p) <br />C)� o.Eo <br />Subscribed and sworn to before <br />0 <br />N <br />co <br />m <br />E <br />.G <br />a7 <br />0 <br />0 <br />z <br />I0 <br />0 <br />0 <br />N <br />m <br />My Commission Expires: <br />CERTIFICATION <br />yu) 0 .... <br />w .0 •c N m <br />u) 0 E • .a L E H a <br />c -8 . >. <br />�q ca <br />c fll _N N <br />c O 0 w <br />a 0 ,a3cui <br />m <br />== >. 0 <br />co•mY <br />L- <br />C -2 � C <br />'$ 0 8� <br />oID.�� <br />m0'aE <br />c.�� <br />� <br />m • E E v7 <br />H 0 0 0 E <br />a2 0 m <br />ooa <br />8 �� <br />L y c C <br />e a' 6 <br />y= ° 0-g-° <br />LC mo ) 10 <br />,$)5,=zo o•m <br />to w 5 3 Ea <br />,n8o <br />-a€ <br />E <br />E88o- <br />CERTIFIED AMOUNT <br />m <br />_a <br />L 1-- <br />to 0 <br />c <br />y 7 <br />0 0 <br />a.g <br />N `VV <br />pp O <br />C 5 <br />00 <br />.n <br />o <br />c' <br />O -0TS <br />) <br />f0 <br />(0(0 <br />c o <br />m <br />L •0 <br />o 'm <br />ao <br />S <br />0 <br />0 0 <br />0. 0 <br />G <br />16' <br />0 un <br />c 0 c <br />0 0 <br />� <br />" 0 E <br />ao °o <br />Q-00 <br />oo <br />zap <br />CONTRACTOR'S SUMMARY OF WORK <br />1. CONTRACT AMOUNT <br />o 00 <br />0 0 <br />v )l) <br />N t0 <br />vi .-• <br />2. SUM OF ALL CHANGE ORDERS <br />3. CURRENT CONTRACT AMOUNT <br />0 <br />0 <br />0 <br />0 <br />4. TOTAL COMPLETED AND STORED <br />(Column G on Continuation Page) <br />5. RETAINAGE: <br />0 <br />0 <br />4* <br />C) <br />0) <br />00 <br />0 <br />69 <br />8 <br />0 <br />co <br />a <br />0 m <br />co 0 <br />0 ) <br />,Le m a o 0 <br />7 a Lo c <br />0 6 8W a+ 0 <br />is c � 7 <br />0. 0 C C a) <br />Uw <br />� o d <br />O 0 O u 0 6D <br />O c <br />a c o c = <br />o E o E `0 E <br />O c O 7 N 7 <br />o(jo8'To <br />0 <br />6 a F- <br />0 <br />0 <br />0 <br />a <br />6. TOTAL COMPLETED AND STORED LESS RETAINAGE <br />(Line 4 minus Line 5 Total) <br />• <br />0 <br />ui <br />N <br />0 <br />7. LESS PREVIOUS PAYMENT APPLICATIONS <br />(Line 6 from prior Application) <br />8. PAYMENT DUE <br />9. BALANCE TO COMPLETION <br />0 <br />0 <br />0 <br />4* <br />(Line 3 minus Line 6) <br />QSS, INC. DOCUMENT <br />PAYMENT APPLICATION <br />00 <br />00 <br />00 <br />o <br />0 <br />0 <br />DEDUCTIOt <br />V} <br />E9 <br />69 <br />0 <br />0 <br />0 <br />m <br />69 <br />Z <br />0 <br />H <br />O <br />0 <br />Q <br />SUMMARY OF CHANGE ORDERS <br />Total changes approved in <br />previous months <br />Total approved this month <br />1 <br />TOTALS <br />NET CHANGES <br />QSS, INC. DOCUMENT <br />PAYMENT APPLICATION <br />