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REQUEST FOR PAYMENT <br />DATE: October 22, 1984 <br />PLACE: Orono, Minnesota <br />PROJECT: 1984 Seal Cnat Project <br />PROJECT NO.: FILE NO.: 13924 <br />CONTRACTOR: Buffalo Bituminous, Inc. <br />ADDRESS: Box 337 <br />Buffalo, Minnesota 55313 <br />REQUEST FOh PAYMENT NO.: 1 <br />SUMMARY: <br />1, <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />9. <br />10. <br />11. <br />Original Contract Amount <br />;hange Order - ADDITION $ <br />Change Order - DEDUCTION $ <br />Re%ised Contract Amount <br />Value Cnmplpted to D-.te <br />Material on Hand <br />Amount Earned <br />Less Retainago 5 X <br />Sub -Total <br />Less Amount Paid Previously <br />AMOUNT DUE THIS REQUEST FOR PAYMENT NO. <br />OWNER APPROVAL: <br />By <br />FOR PERIOD: <br />Frnm: Aug. 15 <br />R <br />1984Tn Oct. 15. 1984 <br />67,422.00 <br />$ <br />67,422.00 <br />$ <br />62,197.28 <br />$ <br />0.00 <br />$ <br />62,197.28 <br />$ <br />3,109.86 <br />$ <br />59,08i.42 <br />$ <br />0.00 <br />1 _ $ <br />59,087.42 <br />Approved By: BONESTR00, ROSENE, ANDERLIK b <br />ASSOCIATES, INC. <br />By: <br />By <br />Date: Approved By: Buffalo Bituminous, Inc. <br />Contractor <br />By: <br />2643c <br />