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Fee <br /> le <br /> IN rrr <br /> AFF <br /> IF r <br /> 77 <br /> Ilt <br /> Dated <br /> Flee I ( CONTRACTOR ) `' <br /> ByI FP <br /> : <br /> IF — <br /> :. IF <br /> State of <br /> I ' ICountAN IF"I <br /> IN A" y of : <br /> Subscribed and sworn to before me this <br /> day of <br /> Notary Public <br /> IF <br /> IN My Commission expires : <br /> Felt <br /> IF <br /> 11 INN Fee CERTIFICATION OF ARCHITECT OR CONSULTING ENGINEER WHERE APPLICABLE11 w11. <br /> I certify that I have checked and verify the above and foregoing Periodic Estimate for <br /> Partial Payment ; that to the best of meel <br /> knowledge and belief it is a true and correct statement of the work performed and/or material supplied by <br /> the Contractor . y <br /> I~,, <br /> IN <br /> eee <br /> Fee <br /> eee DatedFIV <br /> I INN <br /> IN <br /> (ARCHITECT / ENGINEER ) SIGNATURE 11 <br /> IF IF CERTIFICATION OF ENGINEER / INSPECTOR : <br /> le <br /> I have checked the estimate against the Contractor' s Schedule of Amounts for Contract Payments and the notes <br /> and reports of my el <br /> inspections of the project . It is my opinion that this statement of work performed and/or materials supplied is accurate , <br /> that the Contractor <br /> is observing the requirements of the Contract , and that the Contractor should be paid the amount requested above <br />. <br /> Dated <br /> 4x <br /> I INN <br /> (ARCHITECT / ENGINEER ) SIGNATURE <br /> Accompanying Documentation : <br /> le <br /> Fettle <br /> 1 . 11 <br /> FA <br /> Net <br /> IF <br /> Fell <br /> IN <br /> IF <br /> IF) 11 <br /> I INN V It IF <br /> 00800 - 28INN <br />