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APPLICATION FOR PAYMENT <br />CD <br />N N <br />O N <br />Application Date: <br />City of Ramsey Public Works <br />19520-0180 <br />Project No.: <br />0 <br />Contract Date: <br />Z M <br />j M co <br />1= O O In <br />0� cn"Z <br />(n O Z O c <br />0) c� -773 as <br />UQ <br />u_ <br />U) (On O > � <br />o O � <br />>,Fn E L r-� ED <br />5Lo co a)O ap <br />U r` Ce 2 N ls_. <br />E <br />2 <br />195200180-071005 <br />Commitment: <br />C O S <br />O ; <br />▪ § O. `) <br />g U - U <br />C � U <br />6- ▪ o 9 <br />U <br />cac <br />o -o ` <br />5a) <br />. o 0 <br />o. O <br />• U O <br />U U {E <br />E. <br />2 c c E <br />O N U O <br />• a)-o <br />a) U } <br />�L > 2 <br />O C -a a) <br />00) <br />• aE <br />b <br />O a) <br />E a <br />rt3L c <br />m <br />▪ .0 <br />w Q. a) <br />EQo`�S <br />E .� -0 <br />:La <br />2-o-o c c <br />C 0) a) •- <br />o o,E2 <br />U >c�a) <br />oOc� <br />o 8�L0 <br />C <br />OWQ <br />-ant <br />-• L- E <br />O C) <br />H.aUU n. <br />O <br />O <br />O <br />Ea <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 />0 <br />Ea <br />3. CONTRACT SUM TO DATE <br />O <br />0 <br />H <br />Z <br />0 <br />0 <br />O <br />O <br />O <br />O <br />O <br />10 <br />ua <br />COMPLETED AND STORED TO DATE <br />0 <br />0) <br />N <br />N <br />C <br />a) <br />0) <br />C <br />a) <br />—) <br />c <br />E <br />0 <br />U <br />5. RETAINAGE <br />5.00% of Completed Wor <br />Subscribed and sworn to before me this <br />(Columns D f E) <br />Ct.. <br />O <br />2 <br />5.00% of Stored Mate <br />My commission expire <br />E <br />0 <br />U <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />Total Retainage <br />(Line 5a + Line 5b OR Sum of Column l) <br />VY U <br />U � <br />a) a <br />U) U <br />6 Ua.8 <br />-0Q'O C <br />a) 0) fii U <br />- 22o <br />O Q <br />crj(Q • d "C <br />O O <br />aa) <br />) a <br />▪ C <br />O U <br />+� ❑ <br />•� C (1t) <br />C a) <br />o a)50 <br />L L U <br />E O O.o <br />• a) 1 <br />▪ U <br />O O -o o <br />E- °U <br />=Ea) <br />U Q L U �--- <br />❑ o`6 c <br />U"a).2O <br />C.a <br />O II a 0 Q <br />UO2La) <br />a) Z. CO O <br />n +, ), O <br />— c `Jc <br />_,.0 E a) <br />0K9-E <br />U C O <br />C o a <br />10 E - .a o <br />a) <br />O O <br />o c Q <br />C• O C C � C <br />U 1 a) <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 Iess Line 5 Total) <br />7. LESS PRIOR CERTIFICATES FOR PAYMENT <br />OUNT CERTIFIED $4,750.00 <br />(Lin e 6 from prior Certificate) <br />8. CURRENT PAYMENT DUE <br />f} <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />ARCHITECT: <br />(Line 3 Iess Line 6) <br />a) <br />(0 <br />DEDUCTIONS ] <br />O <br />O <br />O <br />ea <br />O r <br />O <br />O <br />ea- <br />O <br />O <br />O <br />Ea <br />"Mlj <br />O <br />O <br />O <br />03 <br />SNOI.LIOOV <br />IwA...._ <br />0 <br />O <br />O <br />Ea <br />. <br />O <br />O <br />g O <br />L Ea <br />e <br />O <br />O <br />O <br />Eft <br />FCHANGE ORDER SUMMARY <br />Total changes approved in previous months <br />Total approved this month <br />[TOTALS <br />J <br />NET CHANGES by Change Orders <br />