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<br />APPLICATION FOR PAYMENT - Continued . .
<br />Total Contract Amount $ 19,506.00 Total Amount Earned $16,120,13 .
<br />Material Suitably Stored on Site, Not Incoporated into Work $
<br />Contract Change Order No, Percent, Comp 1 ete $___
<br />Contract Change Order '10 , Percent Compl ete $
<br />Contract Change Order No, Percent Complete S
<br />
<br />
<br />GROSS AMOUNT DUE............... $16,120,13
<br />
<br />LESS % RETAINAGE......... $ -0-
<br />
<br />AMOUNT DUE TO DATE............. $16,120.13
<br />
<br />LESS PREVIOUS APPLICATIONS..... $ -0-
<br />
<br />AMOUNT DUE THIS APPLICATION.... $16,120.13
<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 />
<br />D d n I:; J" 19 cc 1 __
<br />ate /.--<./"" 'q Ace B acktop, Inc,
<br />I :', (contra\tor)l cj /,
<br />iff .- C [ I)/} (",
<br />By Uu</ ,/).:J('1'Cu..I:'.!/ .~({'
<br />j' (-Name and Title)
<br />
<br />COUNTY OF ,~t:J-()lt0 ) SS
<br />STATE OF /H;I///'-""6-!Z<j )
<br />r ~i-lf
<br />3efore me on this <,', day of December , 1989 personally aDpeared
<br />Alpx D, Sr.hield known to me, who being duly sworn, did deJose
<br />Jnd say that he is the Secretary of the Contractor above mentioned;
<br />(Offi ce) _
<br />that he executed the above Application for Payment and Affidavit on bkhalf of said Contractor;
<br />and that all of the ~:~~~~~;",~!,j,,~~~~'~~~~;~~~\t7e ;rue, cOJ/~~ct ld complete.
<br />" ,<,,,,.,;,,,.r.r__4,,,L~,, ,,1, SL'_LI,;" ~, ,.,L 'c, ! I. i'..', ,/
<br />My Comml ss 1 on Exp 1 res.,..'''''"""., 1','0', ..O'{ f'U,,"L"- '.", ',"........, 1/ /c1! '.., II . I/. /-'-/,,>c ,.( _'" '/
<br />< '~~r":' . ......to ,.-' h,-" "~".'-'uJ'\ '" " _"'_" __ .
<br />~ ''"''"!: DP,;.:oTf,COU"'lj',"'" i (Notary Public) 'I
<br /><. My Commissioii Expires 6-15-94 J /
<br />The undersigned has ~~~tr~s~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 CDntract 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 />
<br />In accordance with the Contract, the undersigned approves payment to the Contractor of the
<br />Amount Due, .
<br />
<br />SHOR~LIOTT ~DRICKSON, INC.
<br />Date Jr~ \,(17D By .5 (. J--
<br />
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