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DocuSign Envelope ID: 27E728AB-E761-4D8D-8B46-447BC430C75D <br />:CONTINUATION SHEET <br />APPLICATION AND CERTIFICATION FOR PAYMENT, <br />APPLICATION NO.: <br />1 <br />containing Contractor's signed Certification is attached. <br />In tabulations below, amounts are stated to the nearest dollar. <br />APPLICATION DATE: <br />07/24/20 <br />PERIOD TO: <br />07/31/20 <br />Midwest Specialty Maintenance, Inc. <br />PROJECT NO.: <br />19520-0033 <br />A B C <br />D <br />E <br />F <br />G <br />H <br />I <br />WORK COMPLETED <br />MATERIALS <br />TOTAL <br />ITEM DESCRIPTION OF WORK SCHEDULED <br />FROM PREVIOUS j <br />PRESENTLY <br />COMPLETED % <br />BALANCE TO <br />RETAINAGE (IF <br />NUM VALUE <br />APPLICATION (D <br />THIS PERIOD g STORED (NOT IN i <br />AND STORED TO = (G + C) 1 <br />FINISH (C - G) <br />VARIABLE RATE) <br />+ E) <br />D OR E) <br />DATE 3 <br />001 Post Construction Final $70,525.00 <br />- <br />$42,315.00= <br />$42,315.00 60.00%; <br />$28,210.00 <br />$2,11575' <br />!Cleaning- Multipurpose Bldg, <br />General Interior <br />f 002 Post Construction Final $8,526.00' <br />-' <br />$6,395.00 1 <br />$6,395.00 _ 75.01 % 1, <br />$2,131.00 3 <br />$319.75 <br />Cleaning - Multipurpose Bldg, <br />Interior & Exterior Windows <br />003 Post Construction Final $1,600.00 <br />- <br />$1,600.00 <br />Cleaning - Lions Park <br />j <br />1 f Final Cleaning (CO #1) � $376.00 <br />-. <br />-� <br />l <br />$376.00 <br />; <br />PAYMENT TOTALS $81,027.00 <br />$48,710.00 k <br />- <br />$48,710.00 60.12% 1 <br />$32,317.00 <br />$2,435.50 <br />Page 1 of 1 <br />