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REQUEST FOR PAYMENT <br />DATE: October 22, 1984 <br />PLACE: Orono, Minnesota <br />PROJECT: 1984 Seal Coat Project <br />PROJECT NO.: FILE NO.: 13924 <br />CONTRACTOR: Buffalo Bituminous, Inc. <br />ADDRESS: Box 337 <br />Buffalo, Minnesota 55313 <br />REQUEST FOR PAYMENT NO.: 1 <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 />7. Amount Earned <br />8. Less Retainage 5 % <br />9. Sub -Total <br />10. Less Amount Paid Previously <br />11. AMOUNT DUE THIS REQUEST FOR PAYMENT NO.: <br />OWNER APPROVAL: <br />By <br />FOR PERIOD: <br />From: Aug. 15, 1984To Oct. 15, 1984 <br />$ 67,422.00 <br />$ <br />67,422.00 <br />$ <br />62,197.28 <br />$ <br />0.00 <br />$ <br />61,197.28 <br />$ <br />3,109.86 <br />$ <br />59,087.42 <br />$ <br />0.00 <br />1 — $ <br />59,087.42 <br />Approved By: BONESTROO, R )ERLIK 5 <br />ASSOCIATES, I'". <br />By: <br />By <br />Date: Approved By: Buffalo Bituminous, Inc. <br />Contractor <br />By: <br />2643c <br />n L 1. `1 <br />