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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 />APPLICATION DATE: <br />08/05/20 <br />In tabulations below, amounts are stated to the nearest dollar. <br />PERIOD TO: <br />08/31/20 <br />Fireside Hearth & Home <br />PROJECT NO.: <br />19520-0033 <br />A B C D <br />E <br />F <br />G <br />H <br />I <br />WORK COMPLETED <br />MATERIALS <br />TOTAL <br />I <br />ITEM SCHEDULED FROM PREVIOUS <br />DESCRIPTION OF WORK <br />PRESENTLY <br />STO D IN ' <br />COMPLETED % <br />AND SDATE TOREDTO + C) <br />BALANCE TO <br />FINISH G) <br />RETAINAGE (IF <br />VARIABLE RATE) <br />NUM VALUE APPLICATION (D <br />THIS PERIOD (EOT <br />D <br />(G <br />(C - <br />+ E) <br />i <br />1Fireplace 3 $14,15000 <br />$14,150.00 <br />$14,150.00 100.00% <br />$707.50 <br />j PAYMENT TOTALS; $14,150.001 <br />$14,150.00 <br />-, <br />$14,150.00 100.00%_ <br />- <br />$707.50 <br />Page 1 of 1 <br />