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ign Envelope ID: 42FFC03B-5D22-43CD-B492-F5001301 BCBBE <br />Qc?5, <br />APPLICATION FOR PAYMENT <br />Application No <br />Project: City of Ramsey Public Works <br />0 <br />1- <br />0 <br />IL <br />cD <br />N <br />N <br />Application Date: <br />E <br />0 <br />LL <br />19520-0180 <br />6 <br />z <br />0 <br />0 <br />0 <br />Contract Date: <br />195200180-051205 <br />Commitment: <br />0 <br />Q <br />OD <br />co <br />1. ORIGINAL CONTRACT AMOUNT <br />0 <br />0 <br />0 <br />2. NET CHANGE BY CHANGE ORDERS <br />0 <br />0 <br />Cfl <br />(0 <br />C�0 <br />3. CONTRACT SUM TO DATE <br />CONTRACTOR: <br />0 <br />0 <br />0 <br />Lan <br />4. TOTAL COMPLETED AND STORED TO DATE <br />c <br />E <br />0 <br />U <br />0 <br />v <br />c0 <br />(7 <br />5. RETAINAGE <br />42 <br />0 <br />c <br />a <br />0 <br />0 <br />0 <br />5.00% of Completed Work <br />Lio <br />C0 <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 />0 <br />0) <br />0 <br />E <br />0 <br />U <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />0] <br />cn .5 c E <br />m a ❑ c .0 <br />P, -� [A v U ❑ <br />-o d v v ..0 � .N C <br />20 o ° 0 <br />�a o. <br />�yv <br />c 0 0 v c <br />cl�i� (0o cz <br />w <br />'an- ..0 t <br />d t'4,))1 .. a 0 <br />U al 0 <br />tl3 0 2 E o v ❑ o ) <br />C = -0 0) �- <br />-omoc) 2C . <br />Z. <br />0. U Q. D <br />r s <br />o -Ti <br />� `� S. <br />0 o :( 0 <br />vm�c o� v <br />Z.�L�j E,s E. <br />W <br />m AC E <br />0 4a U) W a <br />v - U <br />0 :n Z ar <br />U �I 0 N =z ❑ <br />U cii°L 0 v 8 N <br />Q] ❑ U <br />v 2 o Ili <br />Q .2 0 v U0 CtiI v a. <br />❑ Q] `F' = Z % N I" U 1,.... <br />...,m --� v mU <br />U p� .' Q U C ❑ -0 cn <br />2 c -0 2 �'c -0rSa co <br />-o o< LLl o c o''6 <br />8 2 2 LT,E �v-° <br />vQca``-' Zc c�� <br />0-°>,0 ~ CD rj <br />v u..[ o f .N aS 2 <br />•§' ,s 8 ,- E U c5 � a? � <br />c <br />C C E (!) [� F o U(❑ <br />C[f �4 z �' .2 4]o <br />Egg, D 0❑., _ <br />`o <br />8Q°'�0 8(a va• 2 <br />8Eo"a 2 2,_a-C >, va3c <br />£oc�c < K Q m 15-:20 <br />0 0 <br />0 0 <br />0 0 <br />u� LC) <br />N N <br />N <br />r CO <br />69- <br />Total Retainage <br />(Line 5a + Line 5b ❑R Sum of Column I) <br />6. TOTAL EARNE❑ LESS RETAINAGE <br />(Line 4 less Line 5 Total) <br />a <br />7. LESS PRIOR CERTIFICATES FOR PAYMENT <br />(Line 6 from prior Certificate) <br />a 0 <br />0 0 <br />0 r <br />C\ i <br />CO 00 <br />C\I <br />8. CURRENT PAYMENT ❑UE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />(Line 3 less Line 6) <br />DEDUCTIONS <br />0 <br />0 <br />0 <br />64. <br />0 <br />0 <br />0 <br />0 <br />0 <br />ADDITIONS <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />CHANGE ORDER SUMMARY <br />Total changes approved in previous months <br />Total approved this month <br />0 <br />NET CHANGES by Change Orders <br />