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PAYMENT APPLICATION NO. 1 <br /> ONTRACT SUMMARY: <br /> 1 - Original contract amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . $659.709.90 <br /> 2 - Additions approved to date(Itemize) (Nos. none ) . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 0 <br /> 3 - Deductions approved to date(Itemize) (Nos. none ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 0 <br /> 4 - Revised contract amount to date . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . $659,709.90 <br /> STATUS OF ACCOUNT: <br /> 5 - Contract amount to date . . . . . .. .. . . .... . .. . . . .. ... . . . . . .. . . . . . . . . . . . . . . .. . ... .. . . $659,709.90 <br /> 6 - Value of completed work to date ... . . . .. ..... . ..... . .. . . . . . . . . . . . .. . .. . ... . .. . . . . . $ 70.440.10 <br /> 7 - Material stored on site(Attach Schedule) .... ... .. .. . . .. . .. .. . . . . .. .. . . . . .. . ..... .. . $ NA <br /> 8 - Less 5 per cent retained .... .. . ....... . ... . ... .... .. . . .. . .. . ..... ...... . . $ 3522.00 <br /> 9 - Total earned less retained amount ... . . ........ ..... ...... . . ... . . . . .. . ..... .... .. . . $ 66,918.10 <br /> 10 - Total of estimates previously approved ... ...... .. .. . ... .. . . . . .. . . . . .. . .. . .. ..... . .. $ 0 <br /> 11 - Amount due this estimate .. . . .... .. . . . ......... ... ... ... .... . .. . .. . .. . .. . .... . ... $ 66,918.10 <br /> APPROVAL OF FIELD SUPERVISOR CERTIFICATE OF CONTRACTOR. <br /> • <br /> - I (We) certify that all work for which this request for <br /> payment is made has been completed in full, according to <br /> Date 5 ,�9 S— the plans and specifications and terms of the contract <br /> documents. I (We) also certify that payment has been made <br /> for all just claims for labor, material and services in <br /> APPROVAL OF ENGINEER: connection with the work performed on all preceding <br /> estimates. <br /> The work of the project and this estimate have been <br /> examined and the amount shown is recommended for <br /> payment. MIDWEST ASPHALT CORPORATION <br /> Firm Name <br /> Signature <br /> / 9 � Signature <br /> Date �! ��" � �j <br /> Date <br /> • <br />