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APPLICATION AND CERTIFICATION FOR PAY <br />ENT <br />To Owner: <br />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 />Application is made for payment, as shown below, in connection with the contract <br />Original Contract Amount <br />Change Orders Increased Amount <br />Change Orders Decreased Amount <br />Total Contract Amount <br />Value of Work Performed to Date <br />Material on Hand <br />Amount Previously Paid <br />Total Amount Due <br />Less Retainage of 5% <br />Amount Due this Pay Request <br />Contractor's Certification <br />$417,372.22 <br />+ $0.00 <br />$0.00 <br />$417,372.22 <br />$31,307.75 <br />+ $3,191.13 <br />$19,723.42 <br />$14,775.46 <br />$1,565.39 <br />$13,210.07 <br />Project: <br />Location: <br />Eng. Project No.: <br />Contract Manager: <br />Pay Request No. <br />Period To: <br />North Commons <br />Ramsey, Minnesota <br />RAM12024 <br />D. Lazan <br />CHANGE ORDER SUMMARY <br />Total changes approved by Owner <br />Additions <br />2 <br />31-Jan-2013 <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 , f .. .., ._. .. .. . .. . .. <br />g 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: <br />By: <br />Date: <br />Engineer's Certification <br />State of Minnesota <br />County of �, Q. <br />Subscribed and sworn to before me this t day of -E- lo,r'J O % <br />Notary Public. <br />My Commission Expires: <br />1 - 31-.au ilo <br />JAMI RACHEL NEYSSEN <br />NOTARY PUBLIC -MINNESOTA <br />My Comm. Exp. Jan. 31, 2016 <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 Acknowledge <br />Owner: <br />By: <br />Date: <br />o <br />L AND <br />FORM <br />Landform Professional Services <br />105 South Fifth Avenue, Suite 513 <br />Minneapolis, MN 55401 <br />