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TOTALS 4 Gam= — I I -464 3. ANALYSIS OF ADJUSTED CONTRACT AMOUNT TO DATE (a) Original contract amount;Col- 5 - front of this form; (b) Plus; Additlons scheduled in column 4 above _ (c) Less; O*ductlons scheduled in column 6 above (a) Adjusted contract amount to date 4. ANALYSIS OF WORK PERFORMED (a) Cost of originat contract work performed to date (Col. 7 - Hunt of this form) (b) Estrr work performed to date (Col- 5 above/ (c) Total cost or work performed to oat* (d) Less; Amount retained In accordance with contract terms (SAow, both percent and dollar amount) i C % (a) Net amount earned on Contract work to date (f) Add: Materials stored at close of this period (Attach detailed whedule Bi paid invoice) (g) Subtotal of (e) and (f) (h) Lass: Amount of previous payments (1) BALANCE DUE THIS PAYMENT 5. CERTIFICATION OF CONTRACTOR ti9s 1. - Li(�l — .S44-,14— — 44 -l "44 -,14 - 4i -ie/ — LILaj — Sz►4. Sc yGao-r, fel ».s= According to the best of my knowledge and belief. 1 certify that all Items and amount snown on the face of this Periodic Estimate for Partial Payment are correct: that all work has boon performed and/or material supplied In full accordance with the requirements of the referenced Contract, and or duty authorized deviation; substitutioro, al-.•e•stions; and;o► od.jibiet-16 teat the foreroing is a true and correct statement of the Contract aeCeunt up to and t Including the last day of the period covered by this PL/fpr Jr. Estimaie; that no part of the "Sal -ince Due This Raymer. ' !.as Moen received, a -d that till, undersigned and sus subeontrae-p-4 i.ave compl:ad wiG. -,:I :re labos provisions of sf ieontr. r`f tilY L.4 n . n �GQ)r=ATIt�,.J By!Contractor; nator? o/ A�Aorrnd Representative) (J i 19 Title vim.= 6. CERTIFICATION OF DIRECTOR OF PUBLIC WORKS r 1 certify that I have Checked and verified the above and foregoing Periodic Estimate for Pat)Ial Payment: that to the best of my knowledge and belief it Is a true and correct statement of work performed and/or material supplied by the contractor: that au work and/or material included in line Periodic Estimate has Dean Inspected by me and/or by my duty authorlied representative or assistants and that it has been performed and/or supplied in full accordance with requirements of the reference contract: and that partial payment claimed and requested by the contractor is Correctly Computed on the basis or work performed and/or material subtitled to data. , Signed Date Signed (Director of Public Works) Oat* 9 JUN 13 1984 Boa 57 FADE 400 2. SCMEDIJLE OF CONTRACT CHANGE ORDERS ADDITION; rO 0 GINAL List evory approved change order Issued to date of this request dude It MO work CONTRACT PRICE OEDUCTIOtaS • has been dorso under ow;, Or more such orders FROM CONTRACT PRICE CONTRACT CHANGE ORDERpESCA1PTION TOTAL COST OF ITEMS ADDED BY CHANGE ORDER COST OF CHANGE ORDER ITEMS COMPLETED TO DATE AS SHOWN ON CHANCE ORDERS NO. UATE (1) (2) (3) (a) (5) (6)i e-1 L-4 - L-! ('4 - TOTALS 4 Gam= — I I -464 3. ANALYSIS OF ADJUSTED CONTRACT AMOUNT TO DATE (a) Original contract amount;Col- 5 - front of this form; (b) Plus; Additlons scheduled in column 4 above _ (c) Less; O*ductlons scheduled in column 6 above (a) Adjusted contract amount to date 4. ANALYSIS OF WORK PERFORMED (a) Cost of originat contract work performed to date (Col. 7 - Hunt of this form) (b) Estrr work performed to date (Col- 5 above/ (c) Total cost or work performed to oat* (d) Less; Amount retained In accordance with contract terms (SAow, both percent and dollar amount) i C % (a) Net amount earned on Contract work to date (f) Add: Materials stored at close of this period (Attach detailed whedule Bi paid invoice) (g) Subtotal of (e) and (f) (h) Lass: Amount of previous payments (1) BALANCE DUE THIS PAYMENT 5. CERTIFICATION OF CONTRACTOR ti9s 1. - Li(�l — .S44-,14— — 44 -l "44 -,14 - 4i -ie/ — LILaj — Sz►4. Sc yGao-r, fel ».s= According to the best of my knowledge and belief. 1 certify that all Items and amount snown on the face of this Periodic Estimate for Partial Payment are correct: that all work has boon performed and/or material supplied In full accordance with the requirements of the referenced Contract, and or duty authorized deviation; substitutioro, al-.•e•stions; and;o► od.jibiet-16 teat the foreroing is a true and correct statement of the Contract aeCeunt up to and t Including the last day of the period covered by this PL/fpr Jr. Estimaie; that no part of the "Sal -ince Due This Raymer. ' !.as Moen received, a -d that till, undersigned and sus subeontrae-p-4 i.ave compl:ad wiG. -,:I :re labos provisions of sf ieontr. r`f tilY L.4 n . n �GQ)r=ATIt�,.J By!Contractor; nator? o/ A�Aorrnd Representative) (J i 19 Title vim.= 6. CERTIFICATION OF DIRECTOR OF PUBLIC WORKS r 1 certify that I have Checked and verified the above and foregoing Periodic Estimate for Pat)Ial Payment: that to the best of my knowledge and belief it Is a true and correct statement of work performed and/or material supplied by the contractor: that au work and/or material included in line Periodic Estimate has Dean Inspected by me and/or by my duty authorlied representative or assistants and that it has been performed and/or supplied in full accordance with requirements of the reference contract: and that partial payment claimed and requested by the contractor is Correctly Computed on the basis or work performed and/or material subtitled to data. , Signed Date Signed (Director of Public Works) Oat* 9 JUN 13 1984 Boa 57 FADE 400