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REQUEST FOR PAYMENT <br />DATE: October 10, 1984 <br />PLACE: Orono, Minnesota <br />PROJECT: Handicap Access Ramp - Lakeview Golf Course <br />PROJECT NO.: FILE NO.: 13921 <br />CONTRACTOR: Halvorson Construction Co. <br />ADDRESS: 4227 - 165th Ave. N.E. <br />Wyoming, Mo. 55092 <br />REQUEST FOR PAYMENT NO.: 3rd 6 Final <br />SUMMARY: <br />1. Original Contract Amount <br />2. Change Order - ADDITION <br />3. Change Order - DEDUCTION <br />4. Revised Contract Amount <br />5. Value Completed to Date <br />6. Material on Hand <br />$ 2,395.00 <br />S <br />FOR PERIOD: <br />From: July 15, 1984ToSept. 30. 1984 <br />7. Amount Earned <br />S. Less Retainage 0 T <br />9. Sub -Total <br />10. Less Amount Paid Previously <br />11. AMOUNT DUE THIS REQUEST FOR PAYMENT NO.: 3rd 6 Final <br />OWNER APPROVAL: <br />$ 9,848.00 <br />$ 12,243.00 <br />$ 12,243.00 <br />$ <br />0.00 <br />$ 12,243.00 <br />$ <br />0.00 <br />$ 12,243.00 <br />$ 8,420.04 <br />$ 3,822.96 <br />Approved By: BONESTROO, ROSENE, ANDERLIK 6 <br />ASSOCIATES. INC. <br />By <br />oa te: Approved By: Halverson Construcion Co, <br />Contractor <br />By: <br />0769, <br />