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APPLICATION FOR PAYMENT NO. <br />OWNERI Pro)cat No. . ENGINEERS Project <br />For Work accomplished through the dam of <br />REN <br />eolliTACro al sanrema nFVYuea <br />wedeemolnre <br />uR.I.k. w.naiy Amus <br />wu.Y.y Apwrt <br />3 <br />S S <br />S <br />Tonal <br />S <br />S <br />(Orig. Convect) <br />C.O. Na. 1 <br />C.O. No. 2 <br />Accompanying Dgcu rcrusi ion: <br />CONTRACTOR'S Cenifintion: <br />GROSSAMOUNTDVE ....................... <br />S <br />LESS _90 RETAINAGE ................... <br />5 <br />AMOUNT DUE TO DATE ..................... <br />3 <br />LESS PREVIOUS PAYMENTS ................ <br />S <br />AMOUNT DUE THIS APPLICATION ......... <br />5 <br />The i n designed CONTRACTOR eenldes that (U all previous progress payments received from OWNER on account of <br />Work done under the Cenvact science to above have been applied to discharge in full all obligations of CONTRACTOR <br />incurred in connection with Work covered W Our App inions for Payment numbered I through inclusive: and <br />(2) due to all materials and equipment inmrpotated in said Work or otherwise listed in or covered by this Application for <br />Payment will Oaes to OWNER at time of payment free and clear of all liem. claims, security interests and encumbrances <br />(except such as covered by Bond acceptable to OWNER): <br />19_ <br />By <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated 19— <br />E2CDC No. 1910 g -E (1983 Edition) <br />M1�rWI Er Tar Enainan' Iaim Camnobawmenn Cie inee.M taloned by', AuainNGemNContoaen atilens._ <br />L r 00000-3a <br />