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APPLICATION FOR PAYMENT NO. <br />TO , — +U N1NEit1 <br />COMI—act for - <br />owislr 's Project No, ENGINEIER"s Project No. <br />For Work accomplished through the date of <br />itt: M <br />CONTRACrOR's Schedule of-Velues Work Compteted <br />Unit Prka <br />QusneitY <br />Amount QumthY <br />Amount <br />• Total <br />(Orig. Contract) <br />} C.O. No. 2 <br />i <br />Accompanying Documentation: <br />CONTRACTOR'S Certification: <br />GROSS AMOUNT DUE 5 - <br />LESS 9a RETAINAGE ................... S <br />AMOUNT DUE TO DATE ..................... 5 <br />LESS PREVIOUS PAYMENTS ................ 5 <br />AMOUNT DUE THIS APPLICATION ......... S. <br />The undersigned CONTRACTOR certifies that (1) al1 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 I through , inclusive; and <br />(2) title to all materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for <br />Payment will 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 <br />l9 <br />GONiRACr9it <br />fly i <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated .19 - <br />ENGINEER 19ENGINEER <br />By �-�- <br />EICDC No. 1910•g•E (1483 Edition) <br />PftWtd by tats FA&Wwers' laint Coatn0bm0ftrsty Cwemurce wW eadwred by The Aswcuied Genrnt CeauseWn at Aawfue <br />00800-38 <br />