LSJ CONSTRUCTION Subcontractor Payout Project: Flagpole Pool #1013 Trade: Pools Subcontractor Virgin Islands Gunite Pools Invoice # Phase # Requisition #1 13-150 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 Labor and materials 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: Insurance expiration: May 14, 2011 16-Feb-11 Requisition #1 Partial X Final $200,000.00 $0.00 $0.00 $200,000.00 20% $40,000.00 $0.00 $0.00 $40,000.00 $160,000.00 incl. $40,000.00 JEE approval attached YES NO Submitted Bill Signed: Date: February 16, 2011 Approved by: Emad Signed: Date: YES X Invoice Attached NO Approved by: Signed: Date: EFTA01123615