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APP''CATION FOR PAYMENT - Continued 1r�o 71D 3 <br />f o. 6?,P /� Total Amount Earned <br />_a <br />f <br />Total Contract Amount S <br />Site, Incoporated into Work f 9 <br />Material Suitably Stored on ' Percent .COW Its DO /O _ <br />No. <br />Contract Change Order lete <br />Percent Come <br />Contract Change Order N°• — Complete <br />Percent Come �— <br />contract Change Order NO- — <br />GROSS AMOUNT DUE........... _ <br />LESS <br />X RETAINAGE....... .. S n <br />�— <br />AMOUNT DUE TO DATE ............. $ r. <br />LESS PREVIOUS APPLICATIONS .•••• f 33 6 6 <br />AMOUNT DUE THIS APPLICATION.••• $G progress. <br />malty of perjury that (11 all previous p <br />CONTRACTOR'S AFFIDAVIT swears under penalty performed under the contract referred to <br />he un^_ersigned Contracthe ownetor r account °fdischawork rge in full all obli9atiotundetner said <br />payments received flied by the undersigned to prior Applications for Paymentand (2) all <br />above nave been aPP this <br />signed incurred in connection with work covered by P interests and <br />contract, equipment incorporated in said Project en otherwise listed in interests covered by <br />APp material <br />and <br />dfequipmentt are free and clear of all liens, claims, security <br />encumbrances. Bit) Underground <br />Tl—_, 19 KL• Contractor <br />Dated _ ii/l <br />Byj�,2 Npme.and Title, <br />SS <br />COUNTY OF t� "19 8' personally appeared <br />STATE OF <br />Of rv^',n: ;w:;,�:,: Z_y sworn, did depose <br />sown to me, w o being—d 1 <br />Before me on this l.1�h day of the Contractor above mentioned; <br />a— - o <br />and say that he is the D fits lets. <br />lication for Payment andand of <br />00 behalf le of said Contractor; <br />that he executed the above APp contained therein are true, c ect and camp ----- <br />and that all. of the statements <br />Notary Pu c <br />vy Commission Expires: art of <br />s-s•v? Application for Payment shown payaboments <br />to him <br />him to discharge in full all of his obligations in <br />The undersigned has checked the Contractors Payment. <br />this Application is the ContractoliedAbyivit sicationstfor lPaym ions <br />ender this Contract have been aPP all prior APp of the <br />rd approves payment to the Contractor <br />:onnection with the work covered y <br />In accordancr, with the Contract, the undersign pp SHORT ELLIOTT, INC. <br />HENDRiCKSO <br />Wount Due. �— <br />By <br />)ate <br />age of <br />_� <br />