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APPLICATION OR PAYMENT - Continued <br /> ' ntract Amount $ 271 ,552.5.0 ,Total Amount Earned $ 271, 095.70 <br /> ;; 1 Suitably- Stored on Site, Not Incoporated into Work $ <br />,ntract Change Order No. Percent.Complete $ <br />;ntract Change Order No. Percent Complete $ <br />:ntract Change Order Flo. Percent Complete $ <br /> GROSS AMOUNT DUE.. . . . .. . . . ..... $ 271, 095.70 <br /> "'J• <br /> � LESS Z% RETAINAGE. .. . . .. .. $ 5, 42 <br /> 1.91 <br /> AMOUNT DUE TO DATE.. .. $ 265,673.79 <br /> • LESS PREVIOUS APPLICATIONS.... . $ 257, 540.91 <br /> AMOUNT DUE THIS APPLICATION. .. . $ 8, 132.88 <br />,NTRACTOR'S AFFIDAVIT <br />!e undersigned Contractor hereby swears 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 under said <br />:ntract, and (2) all <br /> aerial and equipment incorporated in said Project or otherwise listed. in or covered by this <br />.:pl ' tion for Payment are free and clear of all liens, claims, security interests and <br /> Ic4ances. <br /> ated February 19, 19 87 Bituminous Roadways, Inc. <br /> Contractor <br /> By <br /> N me and Title <br /> Edward Otremba, reasurer <br />)UNTY OF Hennepin SS <br />-ATE-OF Minnesota <br />?fore me on.this 19th day of February 19 87 personally appeared <br /> Edward J. Otrembi known to me, w o being cTTu y sworn, did.depose <br />.d say that he is the Treasurer of the Contractor above mentioned; <br /> (Office) <br /> ,at he executed the above Application for Payment and Affidavit on behalf of said Contractor; <br /> d that all of the ar ue, rrect and c mpl <br /> �...� DOROTHY M. FRIT E <br /> Expire " KQ��Y ,I��'MINNESOTA <br /> Commission Ex <br /> P ¢ILttJNWO COUNTY <br /> My Commission Expires Feb.20,1980 7Wdr1Fa ry P u 11 c <br /> e undersigned has checked the Contractor's Application for Payment shown above. Apart of <br />.is Application is the Contractor's Affidavit stating that all previous payments to him <br /> :der this Contract have been applied by him to discharge in full all of his obligations in <br /> nnection with the work, covered by all prior Applications for Payment. <br /> afrdance with the Contra, the undersigned approves payment to the Contractor of the <br /> count Due'. - <br /> SHORT EL TT HEN I CKSO I <br /> ate Z�?o 7 By <br /> age 4 of 4 0 <br />