CERTIFICATE

FOR PAYMENT
ARCHITECT'S JOB No 2697

Corydon Wagner OWNER CERTIFICATE No. 4 Revised

TO

Gravelly Lake Drive, Tacoma DATE jan 8

Sept. 1
THIS IS TO CERTIFY THAT IN ACCORDANCE WITH YOUR CONTRACT DATED 19

C. D. West CONTRACTOR

FOR '.esidential Alterations IS ENTITLED TO THE 5th PAYMENT

WHICH IS FOR THE PERIOD November 1 19... _ THROUGH Uovember 30 19 .55 IN THE AMOPNT OF:

FiZlEa HUNDAED 2.1_1,TY TWO AND 35/100 DOLLARS ($ 1,552'35

THE PRESENT STATUS OF THE ACCOUNT FOR THE ABOVE CONTRACT IS AS FOLLOWS:
ORIGINAL CONTRACT SUM $ 29,2)7.9i
ADDITIONS DEDUCTIONS

CHANGE ORDERS APPROVED IN PREVIOUS MONTH'S BY OWNER TOTAL

CHANGE ORDER No. APPROVED 19

CHANGE ORDER No. APPROVED 19
CHANGE ORDER No. APPROVED 19
CHANGE ORDER No APPROVED 19
CHANGE ORDER No APPROVED 19
CHANGE ORDER No APPROVED 19
TOTALS
TOTAL ADDITIONS $
SUB TOTAL $
REMARKS TOTAL DEDUCTIONS $

Non-taxable items total $1,1)13.26 TOTAL AMOUNT OF CONTRACT TO DATE $ 30,950.68

Tax on $27,855.61 WORK STILL TO FINISH (THIS DATE)

DUE CONTRACTOR TO DATE 30,950.68

$ 26.712.35 LESS RETAINAGE $ 3,095.07

TOTAL TO BE DRAWN (TO DATE) $ 27,855.6.1

CERTIFICATES PREVIOUSLY ISSUED $ 27,193,67
(0-N THIS CERTIFICATE 911
3-l/3/3 Sales Tax ... 3 890.41
I 9 °re 07

$ 1 — \ ) <1 This certificate is based on the estimated amount of ')52

worl1 compleetets in
period covered and any retainage shown is deducted therefrom.
the
' LI, This certificate is not negotiable, it is payable only to the payee named
This is to certify that all bills are paid for which previous certificates for herein and its issuance, payment and acceptance are without prejudice to
payment were issued. any rights of the Owner or Contractor under their contract.

CONTRACTOR NICKU LAMONT AND FEY

ARCHITECT

PER DATE 19 By