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APPLICATION FOR PAYMENT NO. <br />,OWNER} <br />To <br />Contmet for , ENGINEER's Project No. <br />owNgWx Project No. <br />For Work accomplished through the date of <br />Accompanying Documentation: <br />GROSS AMOUNT DUE ....................... 5 <br />LESS 9o' RETAINAGE ................... S <br />AMOUNT DUE TO DATE ..................... S <br />LESS PREVIOUS PAYMENTS ................ $ <br />AMOUNT DUE THIS APPLICATION ......... S <br />CONTRACTOR'S Certification: <br />The undersigned CONTRACTOR certifies that (1) an 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 ail 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 />19 t or+rx �c raa <br />Sy <br />— Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated <br />19 - u+oaaeex <br />By <br />F.JCDC No. 1910.8-E (1981 Edition) <br />pr4puto4kkgEntimeegi JointeomosctL79�CYm�gmlA[oplmltngek:;l'%«i' .fir Al �lle�rirt+'ifFftConlfltlgr9gr/1 tP14�. <br />00800-33 <br />