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APPLICATIO N FOR PAYMENT NO. ___ ...;._ ___ _ <br />T o -------------------------------(OWNER) <br />ContBct Cor-------------------------------------- <br />OWNER's Project No.-------------. ENGINEER's Project No.----------- <br />For Work accomplished throuah the date or-----~-------------------- <br />COHTRACTOR't Sched•I• of.Voluu Wortt Coo,pl«td <br />ITT:M Uolt Price Ql,antity ""'°""' Ql,andty ........... <br />s s s <br />' Tot.al s . s <br />(Orig. Contnct) <br />C.O. No. I <br />C.O. No. 2 .... <br />-· <br />Accompanying Documentation: GROSS AMOUNT DUE ..................... .. <br />LESS _91, RETAIN AGE .................. . <br />AMOUNT DUE TO DATE .................... . <br />LESS PREVIOUS PAYMENTS ............... . <br />AMOUNT DUE THIS APPLICATION •.....•.. <br />S----s, ____ _ <br />S----s ___ _ <br />S----- <br />CONTRACTOR'S Certilication: <br />The undcnigned CONTRACTOR certiJics that (I) a.II previous progress payments received from OWNER on account or <br />Work done under the Cona-act referred to above have been applied 10 discharce in Cull 2.11 obligalions or CONTRACTOR <br />incurred io connection with Work covered by prior Applications for Payment numbered I through 'nc:lusivc: and <br />(l) title to all maierials a nd equipment incorporated in said Work or otherwise listed in or covered by this Application for <br />Payment will pass 10 OWNER at time o( payment Cree and clear or all liens, claims, se curity interests and encumbrances <br />(except such as covered by Bond acceptable 10 OWNER): <br />Dated------------, 19 __ COl<TMCTO~ <br />UY-------------------- <br />Payment of the above AMOUNT DUE THIS APPLICATION is re commended. <br />Dated-------------· 19 -- <br />B~--------------------- <br />EJCDC No 1910-8-E (1981 Edition) <br />,., ... ( •• ~, Lh• [ ......," •.... ,c '" ,'D-c\,I .,,. C.-t'fttClU .... ,:a,d o,u4 br TIM Au« ut4 (ic.cr.tC ... oacton .t A,flC'AU <br />00800-3 3