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i ►T )„Z. t'I1 tr � • <br /> To <br /> Contract for <br /> OWNER' s Project No . . ENGINEER' s Project No . ' <br /> For Work accomplished through the data of - <br /> CONT_ MCTOR' s Schedule of Values Wont Completed <br /> tinit Price Quantity Ainouat Quantity Amouot <br /> S S <br /> Total S S <br /> (Ong . Contract) <br /> C . O . No . 1 <br /> C . O . No , 2 <br /> Accompanying Documentation : GROSS AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . S <br /> LESS 5ra RETAINAGE . . . . . . . . . . 44 0 6 4 4 4 4 . S <br /> AMOUNT DUE TO DATE . . . . . . . . . . . . . . . . . . . . . S <br /> err► - - LESS PREVIOUS PAY:dENTS . . . . . . . . . . . . . . . 9 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 I through inclusive : and <br /> ( 2 ) title to all matcrials and equipment incorporated in said Work or otherwise listed in or covered by this Application <br /> for <br /> Payment will pus 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 /> COMMACTOR <br /> r <br /> Ey <br /> Payment of the above AMOUNT DUE THIS APPLICATION is recommended . <br /> Dated . 19 Er+4tt+ titist <br /> tirtr�► B y �_r• • <br /> EJCDC No . 1910 • $ - E ( 1983 Edition ) ' <br /> Prepved by the Enpneers • Joint Contract I o"MCnt7 Committee and endorsed by The Associated General Contractors at America . <br /> 00800-21 <br />