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VI; <br />W <br />00 <br />m <br />U <br />m <br />m <br />0 <br />0 <br />u3 <br />LL <br />C11 <br />07 <br />0 <br />03 <br />m <br />(44 <br />m <br />co <br />u_ <br />N <br />'mot' <br />0 <br />01 <br />0 <br />a <br />0 <br />W <br />r- <br />off:: <br />APPLICATION FOR PAYMENT <br />Application No.: <br />Project: City of Ramsey Public Works <br />0 <br />CCD <br />7 0) <br />0 <br />0 <br />Z <br />.o o <br />❑ CY) <br />N o Ln <br />E 2 <br />cri <br />0 0 <br />E <br />0 <br />Application Date: <br />0 <br />J <br />J <br />C <br />7 <br />(0 <br />X <br />W <br />06 <br />ID) <br />(11 <br />0 <br />0) <br />2 <br />LL. <br />19520-0180 <br />0 <br />Z <br />0 <br />0 <br />13932 Lake Drive <br />CD <br />0 <br />CAI <br />0 <br />Contract Date: <br />Forest Lake, MN 55025 <br />195200180-312205 <br />Commitment: <br />0 <br />0 <br />03 <br />CO <br />0 <br />1. ORIGINAL CONTRACT AMOUNT <br />0 <br />0) <br />0 <br />0 <br />2. NET CHANGE BY CHANGE ORDERS <br />3. CONTRACT SUM TO DATE <br />CONTRACTOR: <br />4. TOTAL COMPLETED AND STORED TO DATE <br />to <br />146 <br />CO C1) <br />C9 <br />0 <br />2 <br />0 <br />U <br />5. RETAINAGE <br />0 <br />O <br />U <br />5.00% of Completed Work <br />0 <br />co <br />Subscribed and sworn to before me this <br />(Columns D + E) <br />Notary Public: <br />5.00% of Stored Materials <br />N <br />c <br />2 <br />0 <br />U <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />0 <br />CO <br />tri <br />Ln <br />Total Retainage <br />(Line 5a + Line 5b OR Sum of Column I) <br />$219,556.40 - <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 less Line 5 Total) <br />$119,530.90 c <br />7. LESS PRIOR CERTIFICATES FOR PAYMENT <br />L V <br />0 <br />0 <br />AMOUNT CERTIFIED <br />(Line 6 from prior Certificate) <br />-2 o <br />C E <br />❑ 03 <br />CO 0 <br />CD <br />� O <br />m <br />a o <br />i33 C <br />0 <br />oa <br />0. U <br />ca <br />0 0 <br />v <br />a)v <br />N <br />o <br />0 <br />a) <br />v <br />0 <br />0 <br />0 <br />0 <br />0 <br />8. CURRENT PAYMENT DUE <br />0 <br />CO - <br />CO <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />ARCHITECT <br />(Line 3 less Line 6) <br />v <br />0 0 <br />C3 <br />C = <br />0 <br />a <br />c <br />0 <br />a. <br />0 0 <br />LL! 2 <br />Li m <br />cr � C <br />a) <br />W E <br />U <br />a <br />z o <br />D <br />0 8 <br /><2=1-0 <br />a, <br />E- o 0 <br />~ �U <br />as -0 w <br />go-o <br />c E 0 <br />L <br />o Q D <br />v <br />33,v" <br />o : <br />o <br />0 L <br />DEDUCTIONS I <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />C <br />0 <br />0 <br />0 <br />6? <br />6 <br />0 <br />CI) <br />Z <br />a <br />0 <br />0 <br />0 <br />6) <br />0) <br />0 <br />co <br />6 <br />0) <br />N <br />m <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 />