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APPLICATION FOR PAYMENT - Continued <br /> z2 . <br /> Contract Amount $ 127 ,090.00 Total Amount Earned $ 7 `� <br /> t ial Suitably Stored on Site, Not Incoporated into Work <br /> Percent.Complete $ <br /> Contract Change Order No. - <br /> wntract Change Order No. <br /> Percent Complete $ - <br /> Complete $ <br /> iontract Change Order tJo. . <br /> - g9. S22i <br /> GROSS AMOUNT DUE. . . . . . . . . . . . . . . $ <br /> LESS _% RETAINAGE $ <br /> AMOUNT DUE TO DATE. . . . . . . . . . . $ 9 <br /> LESS PREVIOUS APPLICATIONS. . • • • $ - <br /> AMOUNT DUE THIS APPLICATION. . S 3 <br /> -ONTRACTOR'S AFF I DAV I T <br /> The undersigned Contractor hereby swears under penalty of perjury that (1) all previo gress. <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 discharges in full all obligations tfutherunder <br /> signed incurred in connection with work covered by p and (2) all <br /> contract, <br /> material and equipment incorporated in said Project or otherwise ted in or covered by this <br /> Application for Payment are free and clear of all Jens, claims, e rity interests and <br /> erobrances. <br /> G 19 • <br /> C tr ctor) <br /> Gated <br /> (Name and Title) <br /> )IJNTY OF RANSE,Y ) SS <br /> SIATE OF 1 ) <br /> Before me on this 6th day of July 1984 personally appeared <br /> ROBERT W. MOORE known to me, who being duly sworn, did depose <br /> and say that he is the PRESIDENT of the Contractor above mentioned; <br /> Office <br /> that he executed the above Application for Payment and A fidavit on behalf of said Contractor; <br /> and that all of the are tr e, torte and complet . <br /> CHP.i 0 DUZ:IAAJ,J°. <br /> My Commission Expires: <br /> N,=.... E•r C0"jr.:T'; Notary Public RIC1 D DUSHAW, JR. <br /> The undersigned has checvMe *re e6onCracCor s pplication 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 /> laccordance with the Contract, the undersigned approves payment to the Contractor of the <br /> Amount Due. <br /> SHORT E I TT HEN2RICKS C. <br /> Date 7 I�bl ¢ By <br />