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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 />5500 Wayzata Blvd, Suite 300 <br />Minneapolis, MN 55416 <br />Contract For: <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />Change Order Summary <br />Change Orders approved in <br />previous months by Owner <br />Additions <br />TOTAL 0 <br />Approved this Month <br />Number Date Approved <br />1 9I1412011 <br />2 10/31/2011 <br />Net change by Change Orders <br />191,057.00 <br />6,249.00 <br />TOTALS 197,306.00 <br />The undersigned Contractor certifies that to the best of the Contractor's knowledge, <br />infonnnation and belief the Work covered by this Application for Payment has been <br />completed in accordance with the Contract Documents, 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 tl Owner, that current payment shown <br />herein is now due. '" ' .• <br />Contractor: <br />By: <br />A ` : ITECT'S CERTIFICATE FOE. PAYMENT <br />accordance with the Contract Documents, based on an -site observations and the <br />data comprising the above oppliontion, the Architect certifies to the Owner that to the <br />best 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 Documents, and <br />the Contractor is entitled to payment of the AMOUNT CERTIFIED. <br />Page One of One <br />Project: Ramsey Municipal Parking Facility - Phase II Application No: <br />Via (Architect): LSA Design Inc <br />219 North Second Street, Suite 302 <br />Minneapolis, MN 55401 <br />Deductions <br />OWNER's CERTIFICATION <br />APPLICATION AND CERTIFICATE FOR PAYMENT <br />Revised July, 2005 <br />0.00 <br />197,306,00 <br />Date: IV ://(f <br />BY: <br />Period To: <br />Architect's <br />Project No: <br />Contract Date: <br />Pages <br />2 <br />1013112011 <br />10-12 <br />8/25/2011 <br />Application is made for Payment, as shown below, in connection with the Contract, <br />Continuation Sheet, attached, <br />1. Original Contract Sum 5 <br />2. Net change by Change Order 5 <br />3. Contract Sum To Date (Line 1 ± 2) <br />4. Total Completed & Stored To Date S <br />(Column G on G703) <br />5. Retainage; <br />a. w % of Completed Work 5 <br />(Column D +Eon G703) <br />b. % of Stored Material $ <br />(Column F on 0703) <br />Total Retainage (Line 5a + 5b or <br />Total in Column I of 0703) <br />6. Total Earned Less Retainage <br />(Line 4 less Line 5 Total) <br />7. Less Previous Certificates For <br />Payment (Line 6 from prior Certificate) <br />8. Current Payment Due <br />9. 'Balance to Finish, Plus Retainage <br />(Line 3 loss Line 6) <br />State of: Minnesota <br />Subscribed and' <br />Notary Public; <br />My Coinmi d n <br />fore me. on t <br />x res:l I an <br />Amount Certified <br />(Attach explanation if crntotrnt celiLeddiffers from the amount applied far) <br />Architect:, <br />61,807.00 <br />0.00 <br />5 <br />S <br />5 <br />Distribution fo:; <br />i Owner; <br />t Architect <br />[En Contractor <br />2,734,000.00 <br />197,306.00 <br />2,931,306.00 <br />1,236,133.00 <br />61,807.00 <br />1,174,326.00 <br />571,169.00 <br />603,157.00 <br />1,756,980.00 <br />County of: Hennepin <br />day of <br />(414ALee--- <br />By: <br />Date: f/ <br />STEPHANIE RENEE RIACH <br />6a <br />Pi Iklic.-Monascd3_ <br />My Commission Expires Jan 31, 2012 <br />This Certificate is not negotiable. The T CERTIFIED is payable only to the <br />Contractor named herein. Issuance, payment and acceptance of payment are without <br />prejudic�to any jglltspthp Owner or Contractor under this Contract. <br />Date: // °' f ,' <br />o � <br />Tab 141 <br />