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From: Nor fh Country Concrete, Inc_ <br />7040 143rd Ave- NW <br />Ramsey, MN 55303 <br />t� <br />REQUEST FOR PAYMENT <br />To: CITY OF RAMSEY <br />7550 SUNWOOD DRIVE NW <br />RAMSEY, MN 55303 <br />Invoice- 83321 <br />Draw- 083320(1003 <br />Invoice date: 512712009 <br />C����jj Period_ ending date: 51271200L9 <br />Contract For. �l A <br />Request for payment: <br />Original contract amount $139,797.00 <br />Approved changes $0.00 Project: 08332 <br />Revised contract amount $139,797.00 ALPINE SKATE PARK <br />Contract completed to date <br />Add-ons to date <br />Taxes to date. <br />Less retainage <br />Total completed less retainage <br />Less previous requests <br />Current request for payment <br />Current billing <br />Current additional charges. <br />Current tax <br />Less current retainage <br />Current amount due <br />Remaining contract to bill <br />$0.00 <br />$0-00 <br />$0.00 <br />$94,353.80 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />$139,797.00 <br />$139,797.00 <br />$45,443.20 <br />$45,443.20 <br />$45,443.20 <br />Contract date: 10/612008 <br />Architect - <br />Scope: <br />CHANGE ORDER SUMMARY <br />ADDITIONS <br />DEDUCTIONS <br />Changes approved in previous <br />months by Owner <br />Total approved this Month <br />TOTALS <br />NET CHANGES by Change Order <br />I hereby certify that: the work performed and the materials supplied to date, as shown on the above represent the actual value of the accomplishment under the terms of the <br />Contract (and all authorized changes thereol) between the undersigned and the CITY OF RAMSEY relating to the above referenced project. I also certify that the contractor has <br />paid all amounts previously billed and paid by the owner. <br />CONTRA,I TOR: North Country Concrete, Inc_ State Of MN County Of ANOKA <br />By: fSubscribed and sore to before me this 3 day oftr# <br />Date: 3 Notary Public C <br />My commission expires: <br />A-pppfted +-rz-P(, d <br />t' _ NQTARY PUBLIC <br />e i MINNESOTA <br />