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DocuSign Envelope ID: 27E728AB-E761-4D8D-8B46-44713C430C75D <br />X610 NYlki1lLAX 9 M ► IM:I:W1 <br />APPLICATION AND CERTIFICATION FOR PAYMENT, <br />APPLICATION NO.: <br />3 <br />containing Contractor's signed Certification is attached. <br />In tabulations below, amounts are stated to the nearest dollar. <br />APPLICATION DATE: <br />07/23/20 <br />PERIOD TO: <br />07/31/20 <br />SKOLD SPECIALTY CONTRACTING, LLC <br />PROJECT NO.: <br />19520-0033 <br />A B C <br />D <br />E F <br />G <br />H <br />j <br />WORK COMPLETED MATERIALS <br />TOTAL <br />ITEM ( DESCRIPTION OF WORK 1 SCHEDULED FROM PREVIOUS <br />! PRESENTLY <br />COMPLETED % <br />BALANCE TO <br />RETAINAGE (IF (' <br />NUM VALUE APPLICATION (D <br />THIS PERIOD STORED (NOT IN <br />AND STORED TO (G + C) <br />FINISH (C - G) <br />VARIABLE RATE) j <br />+ E) <br />D OR E) <br />DATE <br />1 Material $46 415 00 <br />$40,015.00 <br />$40,015.00 86.21% <br />$6,400.00E <br />$2,000.7512 <br />Installation$2,050.00 <br />,. <br />- I <br />$13,245.00 f 86.31% <br />$2,100.00 <br />$662.25 <br />1 Overhead Coiling Door (CO #1) ($8,500.00) <br />- ( <br />- I <br />i <br />($8,500.00)' <br />1 Overhead Coiling Door (CO #2) $350.00 <br />$350.00 i - <br />$350.00 100.00% <br />$17.50 <br />PAYMENT TOTALS $53 ,610.001 <br />$51,210.00 <br />$2,400.00 <br />$53.610.00 = 100.00% <br />$2,680 50 P <br />Page 1 of 1 <br />