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GMS, INC. <br /> APPUCATION AND CERTIFICATE FOR PAYMENT <br /> Project: Ohlson Tank Reconstruction No: 13059.100 <br /> Owner McClave Water Association Contractor: Carrigan Excavating, LLC <br /> Application No. Period from Oil/014`{ to b 4A Li <br /> Application is made for payment,as shown below and on the attached Continuation Sheet(s)in accordance with the Contract Documents: <br /> Original Contract $ <br /> 61,200.00 <br /> Change Order No._ $ <br /> Change Order No._ $ <br /> Change Order No $ <br /> Adjusted Contract Price $ 61,200.00 <br /> Total Amount Due To-Date(from attached Continuation Sheet(s)) $ 42,575.00 <br /> Retainage of Amount Due 5.0% $ 2,128.75 <br /> Total Earned Less Retainage •$ 40,446.25 <br /> Less Previous Certificate for Payment $ <br /> Current Payment Due <br /> $ 40,446.25 <br /> Contract Scheduled %Time <br /> Commencement: 2/1/2014 Completion: 4/1/2014 Used: 18% Complete: 10% <br /> Contractor's Certifications Engineer's Certification <br /> The undersigned Contractor certifies that the work covered by this The Engineer has reviewed this Application accompanying <br /> Application for payment has been completed in accordance with the data and schedules and, having made on-site observations of <br /> Contract Documents, that all amounts have been paid by him for work the work, consistent with his assigned responsibilities,certifies <br /> for which previous Certificates for Payment were issued and payments that to his best knowledge and belief, the quality of the work <br /> received from the Owner, and that the current payment shown herein is performed is in accordance with the Contract Documents,that <br /> now due. the work has progressed as indicated herein, and that the <br /> Contractor is entitled to payment in the amount shown above. <br /> Contractor. Carrigan Excavating,tie Engineer: GMS,Inc. <br /> 30687 County Road 19 611 N.Web- uite 300 <br /> Lamar,CO 81052 Ash Colo�- .0 Spri ,s,CO 80903 <br /> Date: .�'� �) ( u/ <br /> Date: ARIBIED <br /> OWNER APPROVAL: By:CD 111 r/3 —Joel/5/ <br /> GMS,Inc. <br /> cAusermshefywocumentsmockive Ohlson Tank Reconshucilon PayAppxls 1 <br />