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APPLICATION FOR PAYMENT - Continued <br />. <br />fal Contract Amount $ 11,962.80 Total Amount Earned $ ra;518 <br />Lerial Suitably Stored on Site, Not lncoporated into Work $ <br />rdct Change Order No. ____ Percent Complete <br />NLract Change Order No. Peraent Complete $_ <br />,ntract Change Order No. Percent Complete $ <br />07,30 <br />GROSS AMOUNT DUE ............... $ M+5.1840 <br />LESS 5 % RETAINAGE......... $_ <br />AMOUNT DUE TO DATE ............. $ 'P44;z � <br />LESS PREVIOUS APPLICATIONS...,. $ 4,086.67 <br />AMOUNT DUE THIS APPLICATION.... <br />INTRACTOR'S AFFIDAVIT <br />e undersigned Contractor herebyswears under penalty of perjury that (1) all previous progress. <br />yinents 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 y 7 19 !=S.T.F., INC. r \ <br />/ Tyet <br />and litle <br />LINTY OF a2cN ) SS <br />ATE OF <br />fore me on this 6?C1_ day of , 19 C& D.,personally appeared <br />Q^J 6o _known to me, who being duly sworn, did depose <br />1 say that he is the of the Contractor above mentioned; <br />(Office <br />dt 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, corect and complete. <br />Commission Expires: ;pia, OONALD D. DELAGE <br />NOTARY FU7M-11NNOU [A <br />OAMSCY COUNTY Jotary Public <br />MY COMMISSION zxpinas AP,1. 13; 1803 <br />undersigned has checked the Contrac or s pp is or 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 />;inection with the work covered by all prior Applications for Payment. <br />•cordance with the Contract, the undersigned approves payment to the Contractor of the <br />..it Due. <br />SHORT(ELLIOTnT HENDRRIC'KSONf/ INC, <br />By f!a1:Y 4 6.66 <br />P. 2 of 2 <br />