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• APPLICATION FOR PAYMENT = Continued <br /> 127 09.0.00 Total.'Amount Earned <br /> Total. Contract Amount' $ + , _ f <br /> Mori- I Suitably Stored on Site, Not Incoporated into.. Work $ <br /> Contract Change Order No. �_ Percent'_Complete . $-- 7�� lam• <br /> contract Change Order No. _� 1 Percent Complete �� °Jd $ ry <br /> Lontract Change Order No. Percent Complete S <br /> GROSS AMOUNT DUE. . . . . . . . . . .. . . . $ <br /> LESS � RETAINAGE. . . . . .:. . $ <br /> AMOUNT DUE TO DATE. . . . . . . . . . . . . <br /> LESS PREVIOUS APPLICATIONS. . . . . <br /> AMOUNT DUE THIS APPLICATION. . . - -r,- /6a <br /> -ONTRACTOR'S AFFIDAVIT ¢0 ,3S 6 - <br /> The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress. <br /> payments received from the Owner on account of work performed under the contract referred to <br /> above have been applied by the undersigned to discharge in full all obligations of the under- <br /> signed incurred in connection with work covered by prior Applications for Payment under said <br /> contract, and (2) all <br /> m erial and equipment incorporated in said Project or otherwise listed in or covered by this <br /> ication for Payment are free and clear of all liens, claims security interests and <br /> encumbrances. <br /> Gated�� C ractor) <br /> ax ze"l 971/ <br /> (Name and Title) <br /> 11JNTY OF� 'r-I ) SS <br /> b iATE OF / l� j+n • ) <br /> Before me on this day of /1 c- I z.. ,S 7 191 personally appeared <br /> known to me, who being duly sworn, did depose <br /> and say that he is the .,-e , of the Contractor above mentioned; <br /> Office <br /> that he executed the above Application for Payme fidavit on behalf of said Contractor; <br /> and that all of the statements contained there* true plete. <br /> TtRESE BOOR <br /> NOTARY PURL INNES <br /> My Commission Expires: s <br /> pan � S.�xsyl C <br /> The undersigned has checked the Contractor's Application for Payment shown above. A part of <br /> tnis Application is the Contractor's Affidavit stating that all previous payments to him <br /> under this Contract have been applied by him to discharge in full all of his obligations in <br /> *ection with the work covered by all prior Applications for Payment. <br /> In accordance with the Contract, the undersigned approves payment to the Contractor of the <br /> Amount Due. <br /> 8 BSHORT E T HE RICKSO C. <br /> Date y <br />