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APPLICATION AND CERTIFICATION FOR PAYMENT <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 />Project: <br />Location: <br />Eng. Project No.: <br />Contract Manager: <br />Pay Request No. 3 <br />Period To: 30-Apr-2013 <br />North Commons <br />Ramsey, Minnesota <br />RAM 12024 <br />D. Lazan <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 />$417,372.22 <br />+ $0.00 <br />$0.00 <br />$417,372.22 <br />$46,032.75 <br />+ $3,191.13 <br />$32,933.49 <br />$16,290.39 <br />$2,301.64 <br />$13,988.75 <br />CHANGE ORDER SUMMARY <br />Total changes approved by Owner <br />Additions <br />Change Order # 1 <br />Change Order # 2 <br />Change Order # 3 <br />Change Order # 4 <br />Totals <br />$0.00 <br />Deductions <br />$0,00 <br />Contractor's Certification <br />The undersigned contractor certifies that to the best of the Contractors knowledge, information, <br />has been <br />Applications ocompletedin accordancewith <br />the oDocuments, <br />all <br />amounts <br />nits have been paid by the Contractor for Work for which Applicationfor Payment <br />wh ch previous <br />Pa <br />Paymentwere issuedandpayments received from the and that current payment shown herein is now due. <br />Contractor: <br />By: <br />Date: <br />State of Minnesota <br />County of <br />Subscribed and sworn to before me this <br />Notary Public: <br />My Commission Expires: <br />day of <br />Engineer's Certification <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: Christopher Call, PE <br />By: <br />Date: <br />L J� <br />5/21 /2 013 <br />Owner's Acknowledgement <br />Owner: <br />By: <br />Date: <br />o . <br />I. A tv D <br />F OR M <br />Landform Professional Services <br />105 South Fifth Avenue, Suite 513 <br />Minneapolis, MN 55401 <br />