Application for Payment of Contract

2452

February 16, 2012

Payment Amount Requested $24,000.00 for work completed during the period from February 19, 2010 to February 19, 2011 in accordance with contract dated February 17, 2010 in the amount of $24,000.00 for work on the following project: Project Name: Parking Lot A Project Location: 3 14th St

Subcontractor/Supplier Donald Brant

Labor/Material Construction Work

Amount Due $24,000.00

CONTRACTOR:

OWNER/ARCHITECT

James Smith 8 Hayes St San Rafael, California 94901

Rose White 1034 15th St San Rafael, California 94901

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