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Aprilfcaflon for Payment tconllnllf,o
<br />OU I
<br />Total AmOLP-11 E'Zirricr!
<br />Not
<br />Percent corllpOete
<br />GROSS M,wIOUNT DUE
<br />I Cl 4 0 1 .8
<br />4FP IvC.
<br />A*�Fp Nc. G:
<br />LESS 5
<br />5. -1 z (J., e0
<br />'V P hk.
<br />AFP 7-
<br />AMOUNT DUE TO DATE
<br />02.98 1.75
<br />VP
<br />AFP N..--.. e.
<br />LESS PREVIOUS APPLICATIONS
<br />A? P No.
<br />AFP No, 9.
<br />AMOLLNl' DUE Ti . 113 APPLICATION
<br />10-,4 19u1."S 1
<br />AFr- W
<br />CON'rRACTOR'S AFFIDAVIT
<br />hat. "0 "..Clvl�- j Y, )Us proglOSs payme rits s raC6.'u.d
<br />perf,)m,,ed L1110e,"tho 'Cor-lrnct rr'lerrod tO'abOvc been applind by the widevs�lgn-!Cj 1%
<br />cx
<br />bPrior for
<br />Storm Sev.,.ir Ge-n La'%e. Minflescta, _,-nd L2)a!! rnntc!ia'
<br />proJec" "Dro9ler"Ase Ste(; 41 bY Uhis Aplication for Payinent and free -;nr.i
<br />jp it,
<br />CkM1:E41AS. iflterests and encurnbra.!Kes
<br />2,
<br />JUN
<br />s n-
<br />SS
<br />Orrnsct) QontracW)
<br />(Contractor!
<br />By
<br />and TOe)
<br />23efcre me orf Oiis ". r-,,- - �1, i appeared �y --Z.. personally , peared
<br />I in '
<br />know-i he, q duly
<br />j sworn did depose and
<br />led Ihn! he
<br />t 11,� executed thip
<br />- , s 11-)ffffCN=,� Of thc- Conlric'�oi above men!J-,
<br />-,ve '� :. I , —
<br />pFJv_-:j!;on f-ir Pavn-ient ;wd Alffidav;t or t)(?ha!f•
<br />Jna
<br />015 statewen!s corit,, d t6evein
<br />Al
<br />'UZ-0, ......
<br />8,
<br />-24
<br />the for F.`iy-_mt.rt zh o V! 'nve. A par" C.. 4z
<br />slati-no !hat -IN pre,-vlous
<br />L-en app!jej t-,?,-non to 0i50,,__arqe
<br />fu;, n n ef: ; "11j ;hovinn4. all pt:("; iippl?ca!j -:ills fo,,
<br />the Ccr,,ract., the underslgnpd rercvnmends marovall c')payment,til, 'the ContrIOv- f.�,- lh�t Am,�)urt (Iua.
<br />Short Elliott Hendrickson Inc.
<br />Y xD 0,00
<br />'Date 11.24.2021
<br />Cif� of Gem Lake
<br />C,
<br />I-e
<br />Date 2 of 2
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