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AYYLIUA LIUN FOR PAYMENT NO . <br /> To _ <br /> Contract for OWNER) <br /> OWNER ' S Project No . . ENGINEER ' S Project No . <br /> For Work accomplished through the date of <br /> MEM CONTRACTOR 's Schedule CC values Wont Coatplcted <br /> Unit Price Quantity Amount Quantity <br /> Ansoaat <br /> S S S <br /> Total S _ S <br /> (Orig . Contract) <br /> C . O . No . 1 <br /> C . O . No . 2 <br /> Accompanying Documentation : GROSS AMOUNT DUE S <br /> LESS % RETAINAGE . . . . . . . . . . . . . . . . . . . S <br /> AMOUNT DUE TO DATE . . . . . . . . . . . . . . . . . . . . . S <br /> LESS PREVIOUS PAYMENTS . . . . . . . . . . . . . . . . S <br /> AMOUNT DUE THIS APPLICATION . . . . . . . . . S <br /> CONTRACTOR ' S Certification : <br /> The undersigned CONTRACTOR certifies that ( 1 ) all 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 1 through inclusive ; and <br /> (2) title to ati materials and equipment incorporated in said Work or otherwise listed in or covered by this Application <br /> for <br /> Paymenr. wW 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 . 19 <br /> CONTRACTOR <br /> By <br /> Payment of the above AMOUNT DUE THIS APPLICATION is recommended . <br /> D • . 19 — <br /> ENGINEE1t <br /> By <br /> EJCDC No . 1910-4- E ( 1983 Edition ) . <br /> Prepared by the Engineers ' Joint Contractboeuments Committee and endorsed by The Associated General Contractors orAmeriea . . <br /> e 00800 — 10 <br />