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AYYL1 (: ATLQN FOR PAYMENT NO . <br /> To <br /> Contract for OWNER) <br /> OWNER ' s Project No . . ENGINEER ' s Project Noe <br /> For Work accomplished through the date of <br /> ME .14 VCONTRACTOR'S Schedule o6 Vdues Wont Completed <br /> cut Price Quantity Amount Quantity Amount <br /> S S S <br /> t <br /> Total S S <br /> (Orig . Contract) <br /> C . O . Noe I <br /> ' C . O . No . 2 <br /> ee <br /> Accompanying Documentation : GROSS AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . S <br /> LESS �7o RETAINAGE . . 04 . 0 . 0 . . . . . 0 0 0 0 0 S <br /> AMOUNT DUE TO DATE . . . . . . . . . . . . . . . . . . . . . S <br /> LESS PREVIOUS PAYyiENTS . 0 . 00 . 0 . . . 0040 . . S <br /> AMOUNT DUE THIS APPLICATION . . . . . . - . . S <br /> CONTRACTOR ' S Certification : <br /> The undersigned CONTRACTOR certifies that ( 1 ) all previous progress payments received from OWNER on account of <br /> Work done under the Contract referred to above have been applied to discharge in full all obligations of CONTRACTOR <br /> incurred in connection with Work covered by prior Applications for Payment numbered t through inclusive ; and <br /> ' (2) title to all materials and equipment incorporated in said Work or otherwise listed in or covered by this Application <br /> for <br /> PaymenkwiIl pass to OWNER at time of payment free and clear of all liens , claims , security interests and encumbrances <br /> ( except such as covered by Bond acceptable to OWNER) : <br /> Dated , 19 <br /> CONTRACTOR <br /> By <br /> Payment of the above AMOUNT DUE THIS APPLICATION is recommended . <br /> Dated , l9 <br /> ENGINEER <br /> By <br /> EJCDC No . 1910-8- E ( 1983 Edition ) - <br /> Prepared by the Entincers ' Joint Conteactboeuments Committee and endorsed by The Associated Gencrai Contractors or America . <br /> 0 00800 — 20 <br />