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) <br />(75\ <br />ctS: <br />ID: 42FFC03B-5D22 43CD-B492 F500B01 BCBBE <br />APPLICATION FOR PAYMENT <br />Application No. <br />City of Ramsey Public Works <br />N N <br />O r— <br />CO <br />✓ <br />r <br />r r <br />773 <br />.0 <br />Application Date: <br />E <br />O 2 <br />F— LL <br />19520-0180 <br />3601 TH U RSTON AVE <br />N <br />N <br />195200180-022105 <br />Commitment: <br />Contract For: 195200180-022105 - Survey <br />-a <br />C <br />m .� <br />O •`_r +-� <br />r✓3aa) <br />E U U <br />L C L U <br />• L L <br />a] O Q <br />0) U x <br />0 o m <br />L <br />Y a) ,O 3 <br />u)a00 <br />E�a) <br />+. p m <br />L <br />• o E <br />0CDU2 <br />O <br />01)013 <br />O 2“> <br />▪ 2 >ra) <br />o��� <br />a(L) <br />E <br />p <br />• a) <br />a <br />1TiL = > <br />� N <br />oa <br />E .0 -a <br />2 N <br />a) <br />L p N a) 0 2 <br />u) <br />• oo_C <br />o a) u) <br />U o'(Us <br />a)„Ei3 <br />C L <br />0) O O 0 <br />• a)ai <br />t N 0 a) 0 <br />�—.0UU a <br />O <br />O <br />O <br />N <br />N <br />Ef? <br />1. ORIGINAL CONTRACT AMOUNT <br />O <br />O <br />O <br />Ef} <br />2. NET CHANGE BY CHANGE ORDERS <br />O <br />O <br />Cfl <br />N <br />H9 <br />3. CONTRACT SUM TO DATE <br />11/24/2020 <br />CONTRACTOR: <br />4. TOTAL COMPLETED AND STORED.TO DATE <br />O <br />0 <br />CO— <br />C <br />E <br />O <br />0 <br />0 <br />a) <br />5. RETAINAGE <br />0 <br />>+ <br />C <br />O <br />0 <br />5.00% of Completed Work <br />O <br />(ri <br />0 <br />Subscribed and sworn to before me this <br />(Columns D + E) <br />Notary Public: <br />5.00% of Stored Materials <br />My commission expires: <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />CD <br />Y ) <br />M <br />49 <br />0 .� <br />U <br />O O <br />0.C(130 <br />"a Q a) gO <br />}' 4▪ — 2 CD <br />0 0 <br />CD 173 <br />Q"p <br />c.2 c U) co <br />O • C t <br />U <br />O • O E <br />• m = U <br />o t 0 0 <br />_U0 <br />� L <br />C U 0 <br />• 3a)L <br />O 0' <br />O 0 U O <br />L U <br />o°o2 <br />_� L <br />0 L-0 3 <br />U = 0 <br />U <br />U C <br />C � <br />E• U0 <br />U L O U <br />O Q -cm <br />• O < <br />o.( 0 .2 <br />a)aoo <br />0 D p 0 <br />E C <br />a) <br />om=0›, <br />U C •- W <br />- <br />-2 • E_g)-a ° <br />0oa)m7) <br />U a U +� <br />ca E O <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 less Line 5 Total) <br />LESS PRIOR CERTIFICATES FOR PAYMENT <br />AMOUNT CERTIFI <br />(Line 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />ARCHITECT: <br />(Line 3 less Line 6) <br />d.) <br />0 <br />m <br />DEDUCTIONS <br />r <br />O <br />O <br />O <br />Ef} <br />O <br />O <br />O <br />Ef} <br />O <br />O <br />O <br />Ef} <br />O <br />O <br />O <br />Ef} <br />ADDITIONS <br />O <br />O <br />O <br />69 <br />O <br />O <br />O <br />Eft <br />O <br />O <br />O <br />49 <br />CHANGE ORDER SUMMARY <br />Total changes approved in previous months <br />Total approved this month <br />TOTALS <br />NET CHANGES by Change Orders <br />O <br />a) <br />a) <br />0 <br />