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Change Order Sun <br />Change Orders approved in <br />previous months by °WneI' <br />TOTAL <br />Approved dais Month — <br />Additions <br />0 <br />Deductions <br />0 <br />'—"--- --- <br />191,057.00 <br />6,249.00 <br />Number <br />Date Approved <br />1 <br />2 <br />9/14/2011 <br />10/31/2011 <br />TOTALS <br />I97,306.00 <br />0,00 <br />Net change by Change Orders 197,306 00 <br />Application and Certificate for Payment <br />To (owner): City of Ramsey <br />7550 Sunwood Drive NW <br />Ramsey- MN 55303 <br />From (Contractor): Knutson Construction <br />5300 Wayzata Blvd, Suite 300 <br />Minneapolis, MN 55416 <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, <br />information and belief the Work covered by this Application for Payment has been <br />completed in accordance with the Contract Doeuments, that all amounts have been <br />paid by the Contractor for Work for which previous Certificates for Payment were <br />issued and payments received from the Owner, and"il)at current payment shown <br />herein is now due. <br />Contractor: <br />By: <br />Contract For: <br />CIIITECTtS CERTIFICATE FOR PAYMENT <br />In accordance with the Contract Documents, based on on -site observations and the <br />data comprising the above application, the Architect certifies to the Owner that to the <br />hest of the Architect's knowledge, information and belief the Work has progressed as <br />indicated, the quality of the Work is an accordance with the Contract Doeunents, and <br />the Contractor is entitled to payment of the AMOUNT CERTIFIED. <br />OWNER's CERTIFICATION <br />APPLICATION AND CERTIFICATE FOR PAYMENT <br />Revised July, 2005 <br />Date: <br />Project: Ramsey Municipal Parking Facility - Phase II <br />Vin (.Architect): LSA Design Inc <br />219 North. Second Street, Suite 302 <br />Minneapolis, MN 55401 <br />Page One of One <br />Application is nettle for Payment, as shown below, in connection with the Contract, <br />Continuation Sheet, attached. <br />1. Original Contract Sum <br />2, Net change by Change Order <br />3, Contract Sum To Date (Line 1 ± 2) <br />4. 'total Completed fi Stored To Date <br />(Column G on G703) <br />5. Retainage: <br />a. _% of Completed Work 8 85,056.00 <br />(Column D +E on G703) <br />b. _ % of Stored Material S 0.00 <br />(Column F on G703) <br />Total Retninage (Line 5a + 5h or <br />Total in Column 1 of G703) <br />6. Total Earned Less Retainage <br />(Lino 4 less Line 5 Total) <br />7. Less Previous Certificates For <br />Payment (Line 6 from prior Certificate) <br />8. Current Pa Due <br />9. Balance to Finish, Plus Retninage <br />(Linea less Line 6) <br />State of: Minnesot <br />Subscribed • d s Worn/ . before meson <br />Notary Publ <br />My Comm .': 1 e 'pires: <br />13y: <br />Application No: <br />Period To <br />Architect's <br />Project No: <br />Contract Date: <br />S <br />S <br />a <br />s <br />S <br />S <br />5 <br />County of: Hennepin <br />1 — clay of <br />Amount Certified S <br />(Attach explanation if amount certified differs front the amount applied for.) <br />Architect <br />Date: <br />Pages <br />3 <br />11/30/2011 <br />10 -12 <br />8/25/2011 <br />Date: /,?, <br />This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the <br />Contractor named herein. Issuance, payment and acceptance of payment are without <br />prejudice to any rights of the Owner or Contractor under this Contract. <br />13)': <br />Distribution to: <br />Owner <br />l�l Architect <br />Contractor <br />2 ,734,000.00 <br />197,306.00 <br />9 31,306.00 <br />1,701,133,00 <br />85,056.00 <br />1 <br />1,174,326.00 <br />441,751.00 <br />1,315,229.00 <br />e tl/ 2011 <br />STEPHANIE RENEE RIACH <br />My Commission Expires Jan 31. 2012 <br />Tab 141 <br />