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APPL"ATION <br />FOR <br />PAYMENT - Continued <br />ot51 Contract Amount <br />$ <br />821,483.90 <br />Total Amount Earned <br />$ <br />791,1 7.16 <br />:terial <br />Suitably Stored <br />on Site, <br />Not Incoporated into Wark <br />$ <br />rict <br />Change Order <br />No. <br />1_-_ <br />Percent <br />Complete 1)"I <br />$ <br />60,695.50 <br />ntract <br />Change Order <br />No. <br />_2 -_ <br />Percent <br />Complete 10Oy <br />$ <br />2,798.15 <br />;ntract <br />Change Order <br />No. <br />3 <br />Percent <br />Complete 1OOk <br />$ <br />1,501.50 <br />GROSS AMOUNT DUE ............... <br />$ <br />856,132.31 <br />LESS 0 % RETAINAGE......... <br />$ <br />A6i0UNT DUE TO DATE ............. <br />$ <br />856,132.31 <br />LESS PREVIOUS APPLICATIONS..... <br />$ <br />841,193.60 <br />AMOUNT DUE THIS APPLICATION.... $ 14,938.71 <br />:NTRACTOR'S AFFIDAVIT <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 />Jove 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 />Cbrances. <br />% �1�.t l2/ . 3 19 J i DAWSON CONSTRUCTION, INC. <br />1 Contra cto <br />BY <br />/ 7 <br />(Name and Title) <br />!UNTY OF SS <br />ATE OF <br />fore me on this ., y da of .9) 19 + "; personally appeared <br />known to ,ne, who being duly sworn, did depose <br />d SWthat he is the % „ ,(•..,; L of the Contractor above mentioned; <br />at he executed the above Application for Payment and Affidavit on behalf of said Contractor; <br />d that all of the statements contained therein are true, correct and complete. <br />Commission Expires: Id ; , .• : %J� <br />Notary Public ' <br />e undersigned has checked the Contractor's Application for Payment shown above. A part of <br />is Application is the Contractor's Affidavit stating that all previous payments to him <br />der 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 />Due. <br />SHORT ELLIOTT HENDRICKSON, INC. <br />to <br />By <br />9e 7 of 7 <br />