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(� N r 64..n• &VN . vn tn4.9VI11 WII16 111YCY <br /> fiotal FContract Amount $ 189.700. 00 Total Amount Earned - $ 43.520.00 <br /> Ma Wial"Suitably Stored on Site, Not Incoporated into Work $ <br /> Ontract Change Order No. Percent.Complete $ <br /> Contract Change Order No. Percent Complete $ <br /> Contract Change Order No. Percent Complete $ <br /> GROSS AMOUNT DUE......... . .. ... $ 43,520.00 <br /> LESS 5 % RETAINAGE... . . .. .. s 2,176.00 <br /> AMOUNT DUE TO DATE... .. .. . . . . .. $ 41 ,344.00 <br /> LESS PREVIOUS APPLICATIONS.. . .. $ .00 <br /> AMOUNT DUE THIS APPLICATION. . . . $ 41 ,344.00 <br /> CONTRACTOR'S AFFIDAVIT <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 /> material and equipment incorporated in said Project or otherwise listed in or covered by this <br /> Application for Payment are free and clear of all liens, claims, security interests and <br /> encumbrances. <br /> Gated November 30 , 19 88 Newmech an anies , . Inc. <br /> f Cont ctor <br /> 8y <br /> (NaW an itle <br /> COUNTY OF SS Wayne Henquine Controller <br /> STATE OF <br /> Before me on this day-of , 19 personally appeared <br /> known to me, w being auTy_ sworn, did depose <br /> and say thtt he is the of the Contractor above mentioned; <br /> (Office) <br /> that he executed the above Application for Payment and Affidavit on behalf of said Contractor; <br /> and that all of the statements contained therein are true, correct and complete. <br /> .A ,�� � <br /> My Cor G� <br /> n 4fp1OHLERS <br /> <� N pp BLL MINNESOTA Notary Public) <br /> WASHINGTON COUNTY <br /> My Comm.Expires Oct.14.1993 <br /> The un ers a Contractor's Application for Payment shown above. A part of <br /> this 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 /> connection with the work covered by all prior Applications for Payment. <br /> 0 accordance with the Contract, the undersigned approves payment to the Contractor of the <br /> Amount Due. <br /> SH RT ELL END C. INC. , <br /> Date 'I l 9 <br /> Page 3 of 3- <br />