LSJ CONSTRUCTION Subcontractor Payout Project: Trade: Kitchen #1007 Air Conditioning Subcontractor Atlanta Refrigeration Invoice # Phase # Requisition #01 15-600 Original Contract Sum: Change Orders Submitted & Approved: New Change Orders: Total Work Contracted to Date: Total Work Completed to Date: Less Retainage: Total Payments Made to Date: Total Current Payment Due: Balance to Finish including Retainage: Sales Tax Liability: a. Subcontractor/Supplier is liable, explaii Insurance ex January 4, 2011 Requisition #01 iration: March 26. 2011 $19,026.69 $0.00 5% install only / tax included in contract b. Non-resident Subcontractor/Supplier Bond Applicable: c. Use Tax to be paid by our company: d. Shipping Total Outlays for this contract incl. Sales or Use Tax: JEE approval attached YES NO X Submitted Bill Signed: Jd Date: January 4, 2011 Approved by: Emad Signed: Date: Al\ $0.00 $19,026.69 $938.00 $0.00 $0.00 $938.00 v 4 /4- $18,088.69 None $938.00 Invoice Attached YES NO X Approved by: Gary / Signed: Date: January 4, 2011 Approved by: Signed: Date EFTA00600644

LSJ CONSTRUCTION ubcontractor All Insurance Protect legal name Phase fi Trade Invoice expiration Date Kitchen #1007 "'manta Rerngeretren 15.600 A;r Condiiionno Reaursibon SDI 26-Mac-11 l)ale Revised January a 2011 Payment Partial Final X i nvoice/Recite CO Amount Retainage Due Paid Dale Paid Check., Balance_ j Contract amount COE CO52 10/15:10 19026 in 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 Cosi CO#2 COs3 COM CO85 Air Conditioning 19.026 69 • Descrlaon • Description • Discretion Descnoban Dosalplon Conoacred To Dalo Balance of Contract vdRelatnage 19,020.69 18,06019 EFTA00600645

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