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w <br />co <br />CO <br />0 <br />m <br />m <br />0, <br />m <br />0 <br />0 <br />0, <br />CO <br />O <br />LL <br />LL <br />CD <br />0 <br />C <br />w <br />❑ <br />0n <br />0 <br />0 <br />APPLICATION FOR PAYMENT <br />Application No. <br />Project: City of Ramsey Pub <br />Z <br />CU <br />• a <br />❑co <br />> -0'O <br />rn oo Z <br />E <br />• c� <br />a <br />o� <br />•ULf).� <br />Application Date: <br />Jacon LLC <br />E <br />1— u_ <br />19520-0180 <br />CO <br />0 <br />co <br />0 <br />0) <br />CY) <br />Contract Date <br />195200180-330105 <br />Commitment: <br />0 <br />0 <br />0 <br />1. ORIGINAL CONTRACT AMOUNT <br />0 <br />Cd <br />CO <br />r-6 <br />2. NET CHANGE BY CHANGE ORDERS <br />0 <br />6 <br />3. CONTRACT SUM TO DATE <br />CONTRACTOR: <br />0 <br />est- <br />4. TOTAL COMPLETED AND STORED TO DATE <br />0) <br />❑ <br />By: Sarah Jensen <br />U <br />5 <br />0 <br />0 <br />0 <br />m <br />c0 <br />Cn <br />5. RETAINAGE <br />42 <br />0 <br />0 <br />0 <br />0 <br />0 <br />CO <br />0 <br />C\I <br />5.00% of Completed Work <br />0 <br />C0 <br />Subscribed and sworn to before me this <br />(Columns ❑ + E) <br />C. <br />0 <br />5.00% of Stored Materials <br />My commission expires: <br />LL <br />0) <br />0 <br />5 <br />0 <br />U <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />N <br />0 <br />0 <br />Total Retainage <br />(Line 5a + Line 5b OR Sum of Column I) <br />ti <br />m <br />comN <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 less Line 5 Total) <br />0 <br />7. LESS PRIOR CERTIFICATES FOR PAYMENT <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />ARCHITECT: <br />(Line 3 less Line 6) <br />DEDUCTIONS I <br />0 o <br />0 <br />0 <br />c0 <br />CO <br />r <br />CZI <br />o <br />(0 <br />CO <br />r <br />CN <br />^ <br />0 <br />� <br />r <br />u) <br />z <br />0 <br />Pn <br />0 <br />0 <br />0 <br />0 <br />te. <br />0 <br />0 <br />0 <br />te <br />0 <br />0 <br />0 <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 />