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APPLICATION AND CERTIFICATION FOR PAYMENT <br />To Owner: City of Ramsey HRA <br />7550 Sunwood Drive NW <br />Ramsey, MN 55303 <br />From Contractor: County Line Excavating, LLC <br />5698 345th Avenue NE <br />Foley, MN 56329 <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />Project: <br />Location: <br />Eng. Project No.: <br />Contract Manager: <br />Pay Request No. <br />Period To: <br />North Commons <br />1 <br />31-Dec-2012 <br />Ramsey, Minnesota <br />RAM12024 <br />D. Lazan <br />Application is made for payment, as shown below, in connection with the contract <br />Original Contract Amount $417,372.22 <br />Change Orders Increased Amount + $0.00 <br />Change Orders Decreased Amount $0.00 <br />Total Contract Amount = $417,372.22 <br />Value of Work Performed to Date $20,761.50 <br />Amount Previously Paid $0.00 <br />Total Amount Due = $20,761.50 <br />Less Retainage of 5% - $1,038.08 <br />Amount Due this Pay Request = $19,723.42 <br />Contractor's Certification <br />CHANGE ORDER SUMMARY <br />Total changes approved by Owner <br />Additions <br />Deductions <br />Change Order # 1 <br />Change Order # 2 <br />Change Order # 3 <br />Change Order # 4 <br />Totals $0.00 $0.00 <br />The undersigned contractor certifies that to the best of the Contractors knowledge, information, and belief the Work covered by this Application for Payment <br />has been completed in accordance with the contract Documents, that all amounts have been paid by the Contractor for Work for which previous <br />Applications for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. <br />Contractor: (or c.,4-'TY e-! N k=('.t C. j.'ga_i <br />Date: /// / <br />Engineer's Certification <br />State of Minnesota <br />County of <br />Subscribed and sworn to before me this day of <br />Notary Public: <br />My Commission Expires: <br />In accordance with the contract Documents, based on on -site observations and the data comprising this application, the Enginer certifies to the Owner that <br />to the best of the Engineer's knowledge, information, and belief, the Work has progressed as indicated, the quality of the Work is if accordance with the <br />Contract Documents, and the contractor is entitled to the payment shown herein. <br />Engineer: <br />By: <br />Date: <br />Christopher Call, PE <br />Owner's Acknowledgement <br />1. A N DFOK <br />him Sao iu ii,k1k <br />Landform Professional Services <br />105 South Fifth Avenue, Suite 513 <br />Minneapolis, MN 55401 <br />Owner: <br />By: <br />Date: <br />G j <br />l 1L6ri , /(r/ <br />(%/7//f <br />