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DocuSign Envelope ID: 27E728AB-E761-4D8D-8B46-447BC430C75D <br />1CONTINUATION SHEET <br />APPLICATION AND CERTIFICATION FOR PAYMENT, <br />APPLICATION NO.: <br />1 <br />containing Contractor's signed Certification <br />is attached. <br />In tabulations below, amounts are stated to the nearest dollar. <br />APPLICATION DATE: <br />07/31/20 <br />PERIOD TO: <br />07/31/20 <br />QC Companies <br />PROJECT <br />NO.: <br />19520-0033 <br />I A B <br />C D <br />E <br />F <br />G <br />H <br />I <br />WORK COMPLETED <br />MATERIALS <br />TOTAL <br />ITEM j DESCRIPTION OF WORK <br />NUM <br />SCHEDULED FROM PREVIOUS <br />VALUE APPLICATION <br />PRESENTLY <br />I STORED (NOT IN <br />COMPLETED <br />AND STORED TO 1 <br />% <br />(G + C) <br />BALANCE TO <br />FINISH (C - G) 1 <br />RETAINAGE (IF <br />VARIABLE RATE) I <br />(D <br />THIS PERIOD <br />+ E) <br />D OR E) <br />DATE <br />1 109 6700 Fluid Applied Floor <br />$8 370 00 <br />$8,370.00 € <br />Labor <br />[ <br />?' <br />2 09 6700 Fluid Applied Floor <br />$3,255.00 <br />$3,255.00 <br />Material <br />3 03 3511 SC 1 Labor <br />$26,095.00 1 i <br />$26,095.00 <br />( $26,095.00 <br />100.00% <br />$1,304.75 <br />4 03 3511 SC1 Material <br />$17,800.00 = <br />$17,800.00 <br />- <br />$17,800.00 <br />100.00% _ <br />$890.00 <br />5 &2 Polished Flooring <br />$34,305.00 _ <br />$34,305.00 <br />$34,305.00 <br />100.00% j <br />$1,715.25 <br />[ Labor <br />6 STC 1&2 Polished Flooring <br />$11,430.00 <br />$11,430.00 <br />$11,430.00 <br />100.00%' <br />$571.50 <br />Material <br />f <br />F <br />17 Bond Fee <br />$3 135 00 <br />$2,689.00 <br />$2,689 001 <br />85.77% i <br />$446.001 <br />$134.45 <br />1 ; Polished Concrete (CO #1) <br />$5,595.00 -_ <br />- <br />$5,595.00 f <br />PAYMENT TOTALS <br />$109 985.00 ; <br />$92,319 00 <br />- <br />3 $92,319.00�83.94% <br />$17,666.00 <br />$4,615.95 <br />Page 1 of 1 <br />