Courts Building Systems, Ine. 9192 Port Union Rialto Road West Chester, Ohio 45069 513-860-3030 To: Terex Development & Construction 3200 Madison Avenue Cincinnati, Ohio 45209 Project: Date Invoice # 10/31/2019} 4682 Coffee Exchange 6041 Montgomery Road Cincinnati, Ohio 45213 Payment Terme Description “Amount Draw #2 13,930.00 Total $13,930.00 Fax Email 513-860-9933 lori@courtsbsi.comAPPLICATION AND CERTIFICATE FOR PAYMENT PAGE ONE OF 2 PAGES TO GENERAL CONTRACTOR: PROJECT: Coffee Exchange of Pleasant Ridge APPLICATION Distribution to Terrex Construction 6041 Montgomery Road PERIOD TO: 3200 Madison Road Cincinnati, Ohio 45213, PROJECT NOS: lowner Cincinnati, Ohio 45209 |Const. Mgr FROM CONTRACTOR: VIA ARCHITECT: CONTRACT DATE: JArchitect Courts Building Systems, Inc. IContractor 9192 Port Union Rialto Road West Chester, Qhio 45069 CONTRACTOR'S APPLICATION FOR PAYMENT -Aoplication is made fr payment, a shown below, in connection wth the Contac. “Te undersigned Contractor cates that othe best of the Canactars knowledge, mtrmation and bol he vork covered by his Appeston for Payment hasbeen competed in accordance wih the Conrat Documents. at amour Conuruaton Sets taco Caruicats tr Payment were sued and payments ecewed Yom the Owner an hat cent ‘Bown meron snow oie 4. ORIGINAL CONTRACT SUM-—nnnnnmnne 5 uusso0o] CONTRACTOR. 2. Net change by Change Orders———-§| £ ty . 3. CONTRACT SUM TO DATE (Line 1 +/- 2) | 34,830.00] By: © L C6 Zhebars 4.TOTAL COMPLETED & STOREDTODATE —§ 28,420 0 {Column G on Cenruton Shee) State of ono Notary FuBuC 5. RETAINAGE: County of Ber STATE OF OHIO 2. _100% of Completed Work s| e300] Subscribed and sworn tobefore My Commission Expres ‘Courins D+E on Continuation Sheet) methis alo dayot fagus 2, 2008 b._100%_of Stored Material 3 oe ‘Column F on Continuation Sheet) Notary Pubic QA J Total Relainage (Line 5a + Sb or Total in Column 1 of Continuation Sheet——-_§| acco] CERTIFICATE FOR PAYMENT a Im acconsenee with Contact Doses, based on one observations andthe data compris roinedeatestih ‘ S181] gppleatn the rhe cries tote Ouner at thebestof the Aries owed, raon Anat! te Work hs rogrested as nated the quality ofthe Wk sn aceordanoe wt he 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT Contact Dseuments, nde Corr ened to payment ct te AMOUNT CERTIFIED (Line 6 from prior Certificate} —~ s 720500 8. CURRENT PAYMENT DUE-nmenmnmmem 8 12.97.09 9. BALANCE TO FINISH, INCLUDING RETAINAGE AMOUNT CERTIFIED (Line 3 less Li s 26300 (Atach eanatantemeunt cerited ders _2pptcaton andon ne Conruation Stet tat ae changed conto CHANGE ORDER SUMMARY “ADDITIONS — DEDUCTIONS ARCHITECT. [otal changes approved in previous Imonths by Owner By Date: Total approved this Month ssa00 ‘Ths Corian ot negotiable The AMOUNT CERTIFIED i payable ony othe Gotan named TOTALS] s2.s0000 aren esvoee payment and acceptance of paynet are wha prague ary ait he Oa [NET CHANGES by Change Order 3550000 of Conracer under tis ContacCONTINUATION SHEET "RITAGHMENT TO PAY APPLICATION PROJECT; Coffee Exchange of Pleasant Ridge Page 2 of 2 Pages APPLICATION NUMBER. [APPLICATION DATE PERIOD To: ARCHITECT'S PROJECT NO. z q ol c D__| E F c cl Tem! Description of Work ‘Scheduled Value Work Completed From Previous Application (+E) This Period Waterals Presently ‘Stored (Not in Dore) Total Completed And Stored To Date (D+E+F) (ere) Balance To Finish (c-6) Retainage JFraming, blocking, anywall and insulation Jcow 80000 ‘360000, 7080000 360000, "30000 3480000, ‘360000 [SUBTOTALS PAGE 2 3ae30.00 2450000 7599000) 100% 39.420 00 348200 e000 3.00