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APPLICATION FOR PAYNLNT - Continued <br />0 <br />alai Contract Amount $ <br />821,983.90 Total Amount Earned <br />S'/81,7Y?.56 <br />iterial <br />Suitably Stored <br />on Site, Not Incoporatcd info Work�- <br />artract <br />Change Order No.. <br />1 Percent Complete 91.9P1 <br />S_ 60,120. _ <br />ntract <br />Change Order ito. <br />_ Percent Complete 1001 __. <br />$ 2.798.15 <br />.ntract <br />Change Order ito. <br />Percent Complete. <br />$ <br />GROSS AMOUNT DUE ............... <br />S 844,633.21 <br />LESS _.02 1 RETAiNAGE......... $__ 16 892.62 <br />AMOUNT DUI. TO DATE ............. $ 827,g.59 <br />LESS PREVIOUS APPLICATIONS..... $ 690,645.45 <br />11. <br />AMOUNT DUE THIS APPLICATION.... $ 137 0`;.14 <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 />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 undersaid <br />ntract, <br />ll <br />terial and equipment incorporated in said Project or otherwise listed in or covered by this <br />olication for Payment are free and clear of all liens, claims, security interests and <br />cumbrances. <br />ted /.> 19 _ DAWSON CONSTRUCTION, INC. <br />�ContraGt�) <br />i 9 <br />By <br />/(Name and Title) <br />JNTY OF A,00 SS <br />UE OF <br />fore me on this /S .t15 day of e • IL 19 3'=+. personally appeared <br />�,_ ,r{ • A ee own to nie, who being duly sworn, did depose <br />J say th 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 />I'l!Yf•;l I' A1HENY �`�. 7 a -� <br />Commission Expires; at : <br />.Notary Public <br />undersigned has checked the Contractor's Application for Payment shown above. A part of <br />s 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 />mection with the work covered by all prior Applications for Payment. <br />accordance with the Contract, the undersigned approves payment to the Contractor of the <br />'unt Due. <br />SHORT ELLIOTT HENDRICKSON, INC. <br />By <br />e 7 of 7 <br />