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C��UTRA�TOR'S PAY R�Q�EST' ��s�r��suT�o�v: <br />CP �ail Bridge Trai# Crossing ���v��ACTt�� �� } <br />�ITY tJF ARDEN �ILLS, lil�N Ov��E� {� } <br />B�1 f�RUJ�C`T N�. �'1 �,� ��325 ��vG)NEER {� } <br />�O�DI�G ��. (1) <br />TC���� A!ilI�UNT 81� ��.US APPF�t��l�D Ci����� �Rt�ERS $3� 2,58�.2� <br />�roT��, G�iV��LETED 1/iIC��K T4 D�T� �35,�74.9� <br />TQT�L, S�'C�RED 111�A`��R1AL.S T� �AT� $O.�C� <br />�JED���1�JN ��R S��RED MATE�lA�.S USEfl ��i 1l1�4R� C��PL�TED ��.�� <br />T{����, C��1fP�ETED 1JVORK & �T�R�t� 1111AT�RlALS $3�,�74.94 <br />RETAI��D �'ERCENTAGE � 5�10 � $� ,778.7� <br />�OTAL ANiC�U��" �F �T�I�R P�Y�IIE�TS �� {�E�I��TI�?NS� $�.�� <br />NET A�1lI���T flUE TO �O�T�A�TOR TO DAT� $33,�96.'� � <br />TOT�L Ai1i�0U�VT PAID ��1 PRE�1��15 ES���11�A�ES ��.fl0 <br />PAY �fl�VT�A�T�R AS �STI�AT� ��. '� $�3,79�.19 <br />Certif�cate fi�or �',ar�ia� Pay�e�t <br />i h�reby cer#ify that, to �he bes# �f r�y knovvledge a�d b�l�ef, a!� �terns quanti#�es and �rtces <br />of v�ork and mater�a� s�o�r� on thi� Est�rnate are c�rrec# and �ha# ��I �rork �as been <br />perforrned ir� f��l accor�ance �ith #he ter�s and cor�d�t�ons flf #he Con�raci �or #his project <br />between �he Ov�rr�er an� #�e undersigned �ontrac�or, an� as ar�e��ed �y any <br />au#�o�ized c�an�es, an�d t#�at ��e for�going is a true and c��rec# sta#ernen� of the <br />contra�i amount for the per�od cov�red by th�s �stir�ate. <br />Contr�c�or: �lacks�one C�ntractor� <br />7�7� Cor�oran Trai� East <br />rco�ar�, Nl� 5�34Q <br />� <br />s <br />g��� ��.,,_.,..� � 1�`-.��.�.:�-`� ' <br />Y <br />Narn� �"it�e <br />���� <br />�3aie '� <br />����KED �ND APPRflVED AS �"{� Q�lA1V�"iTiES AND AlUi0��1T: <br />�NG�N�ER: BOL�ON & 111��NK; 1��., Ei�G�NE�RS, � 2224 NiCi7LL�T �VE., gI�RNSVlL��, �N ��33�. <br />� <br />. <br />By , C�TY EN�INEER <br />Date o� <br />� � <br />AP�'R�VED ��R �'AYMEi��": <br />OVil� E#�: <br />Sy <br />Name Ti�1e flate <br />A�d <br />�am� Title Da�e <br />