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APPLICATION FOR PAYMENT - Continued <br />7,30 <br />Lai Contract Amount $ 11,962.80 Total Amount Earned <br />Lerial Suitably Stored on Site, Not Incoporated into Work <br />�Lract Change Order No <br />,ntract Change Order No <br />ntract Change Order No <br />Percent. Cony letc <br />Percent Complete <br />Percent Complete <br />GROSS AMOUNT DUE ............... <br />.- 17.3J <br />8,'Ifl: 90 <br />LESS 5 % RETAINAGE......... $ Q 5-. 3 1 S, <br />AMOUNT DUE TO DATE ............. s blYI <br />LESS PREVIOUS APPLICATIONS..... $ 4,086.67 d <br />,IITRACiOR'S AFFIDAVIT AMOUNT DUE THIS APPLICATION.... $ 4r866:z 7 101f, <br />e undersigned Contractor herebyswears under penalty of perjury that (1) all previous progress. <br />yments received from the Owner on account of work performed under the contract referred to <br />ove have been applied by the undersigned to discharge in full all obligations of the under- <br />gned incurred in connection with work covered by prior Applications for Payment under said <br />ntract, and (2) all <br />terial and equipment incorporated in said Project or otherwise listed in or covered by this <br />plication for Payment are free and clear of all liens, claims, security interests and <br />cumbrances. <br />d a' 1 , 19�_Z G.T.F. <br />( i�11 <br />By Pai11 at <br />LINTY OF �\i\,10 5-u1c ) SS <br />ATE OF 4N ) <br />fore me on this Q 9 _ day of �..� . , 19 personally appeared <br />known to me, who being duly sworn, did depose <br />11 say that he is the _ �•� of the Contractor above mentioned; <br />Office <br />,it he executed the above Application for Payment and Affidavit on behalf of said Contractor; <br />.I that all of the statements contained therein are true, correct and complete. <br />Commission Expires: t Do0 NAL�DID_DELAoA <br />n n 01 n <br />NARYRAMSEY COUNTY (Notary Public <br />.. <br />MY COMMunoM nnn[e APR, 19: 1003 <br />�mdersigned has chetklsE plication for Payment shown above. A part of <br />is Application is the Contractor's Affidavit stating that all previous payments to him <br />Ier this Contract have been applied by him to discharge in full all of his obligations in <br />onection with the work covered by all prior Applications for Payment. <br />:ordance with the Contract, the undersigned approves payment to the Contractor of the <br />,t Due. <br />e g , SHORT ELLIOTT HENDRICKSON, INC. <br />BYLTA--- <br />e 2 of <br />