EFTA00600644

LSJ CONSTRUCTION Subcontractor Payout Project: Kitchen #1007 January 4, 2011 Trade: Air Conditioning Requisition #01 Subcontractor Atlanta Refrigeration Insurance ex iration: March 26. 2011 Invoice # Requisition #01 Phase # 15-600 Original Contract Sum: $19,026.69 Change Orders Submitted & Approved: $0.00 New Change Orders: $0.00 Total Work Contracted to Date: $19,026.69 Total Work Completed to Date: 5% $938.00 Less Retainage: $0.00 Total Payments Made to Date: $0.00 Total Current Payment Due: $938.00 v 4 /4- Balance to Finish including Retainage: $18,088.69 Sales Tax Liability: a. Subcontractor/Supplier is liable, explaiiinstall only / tax included in contract b. Non-resident Subcontractor/Supplier Bond Applicable: c. Use Tax to be paid by our company: d. Shipping None Total Outlays for this contract incl. Sales or Use Tax: $938.00 JEE approval attached Invoice Attached YES NO YES NO X X Submitted Bill Approved by: Gary / Signed: Signed: Jd Date: January 4, 2011 Date: January 4, 2011 Approved by: Emad Approved by: Signed: Signed: Date: Al\ Date EFTA00600644 LSJ CONSTRUCTION Protect Kitchen #1007 ubcontractor All legal name "'manta Rerngeretren l)ale Revised January a 2011 Phase fi 15.600 Trade A;r Condiiionno Invoice Reaursibon SDI Insurance expiration 26-Mac -11 Payment Partial Final X i nvoice/Recite Contract amount COE Date 10/15:10 CO Amount 19026 in Retainage Due Paid Dale Paid Check., Balance_ j CO52 COa3 COtta CO-5 Requisition MI 01104'1 I Req. II 930 00 0.00 93000 938 00 Roqusition #2 0.00 Requisition #3 000 Requisition #4 000 Requizabon #5 Requisition 06 Requisibon 117 Row,SitiOn #8 Requisition 59 Total I 935 00 0.00 038.00 I 0.00 938 00 Contract Amount - Ruse Contract Air Conditioning 19.026 69 Cosi • Descrlaon CO#2 • Description COs3 • Discretion COM Descnoban CO85 Dosalplon Conoacred To Dalo 19,020.69 Balance of Contract vdRelatnage 18,06019 EFTA00600645 EFTA00600646 EFTA00600647