G736cma - Project Application For Payment Form
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1From:
Project:
Page: 1 of 2
This Application
*Test PEM Software Systems
FO BUCK
Distributed To:
Clayton, NC 27528
PAIN IN BUT
Number:
3
Date:
7/29/2010
Owner
Phone:(919)639-7025
Architect
Billing Period:
/ /
7/29/2010
Contractor
Construction Mgr
Project No:
Original Date of Contract:
7/29/2010
Contract For:
Project Application for Payment -
CAP736/CMa
To:
Section A:
Contract Amounts
T & M CONTRACTING
A.1 Contract Sums
100.00
$________________
,
50.00
A.2 Total Changes By Change Orders
$________________
150.00
$________________
A.3 Total Contract
Construction Manager:
Section B:
Retainage
The Construction Mangers signature here certifies that, to the best of thier knowledge,
this document accurately reflects the work completed and billed this Application.
0.00
$________________
B.1 Total Retainage
Date:
7/29/2010
( Authorizing Signature )
Section C:
Billing Information
State Authorized:
NC
75.00
C.1 Total Contract Billed To Date
$________________
County of:
Johnston County
75.00
C.2 Total Billed Minus Retainage
$________________
Subscribed and sworn to before
me this
day of
25.00
C.3 Previous Applications For Payment
$________________
Notary Public:
50.00
$________________
C.4 Payment Due This Application
My Commission expires:
/ /
The Architects and Construction Managers signature here certifies that, based on
their own observations and the information contained herein, this document
accurately reflects the work completed and billed this Application.
AMOUNTS CERTIFIED ................................................$_____________________
_________________________________________ Date:_____________
( Construction Manager )
_________________________________________ Date:_____________
( Architects Signature )
forms and Software by; PEM Software 1-800-803-1315
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