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<br /> --..-...--- <br /> 'Total Contract Amount $ 11, ,15 .00 Tota I Amount tarned $11,225.60 <br /> .. Material Suitably Stored on Site. Not Incoporated into Wor; $ <br /> . <br /> / ' <br /> Contract Change Order No. Percent. Complete $ <br /> . Contract Change Order No. Percent Complete $ <br /> Contract Change Order No. Percent Complete $ <br /> GROSS AKlUNT DUE............... $11,225.60 <br /> LESS 0 % RETAINAGE......... $ <br /> AKlUNT DUE TO DATE......;...... $11.225.60 <br /> LESS PREVIOUS APPLICATIONS..... $ 9,941.75 <br /> AKlUNT DUE THIS APPLICATION.... $ 1, 283 . 85 <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 /> Dated December 18, .19~. RO-SO CONTRACTING <br /> . (Contractor) <br /> ByWq~ ~\~m&' President <br /> I <br /> COUNTY OF Washington I SS <br /> STATE OF Minnesota <br /> 3efore me on this 18th day of December . 1989 personally aopeared <br /> Henry A. DaBruZZl known to me. who being duly sworn, did deoose <br /> lnd say that he is the President 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 /> My COlMlisslon Expire' . .~~ m H <br /> The unders igned has. , , plication 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 /> In accordance with the Contract. the undersigned approves payment to the Contractor of the <br /> Amount Due. <br /> . \} ::JIOTTOH:"fJ-KSON. INC. <br /> Date c.-.. 2., Iq~o <br /> I rs <br /> Page 3 of 3 <br />