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DocuSign Envelope ID: 74A66727-20DF-4329-9253-19EDEA1 C9B7F <br />Distribution to : <br />m <br />0 <br />Project: 19520-0180 City of Ramsey Public Works <br />a) <br />C <br />I- 0 <br />Application No. <br />Ramsey, MN 55303 <br />O <br />`o 1- -6s r- <br />c O <br />0 O <br />U a) <br />E c <br />O <br />O <br />co)U. <br />0)c <br />O a) E <br />N .0 > O <br />Q 0 m -0 co 0 <br />c .0 • > (NJ <br />n "o c)• a) c a0i (NI0 ▪ E a) <br />U .9 co � <br />CO a)c <br />tl N 0r-i <br />N <br />� � T H <br />U a) ai <br />CD •� n (0 <br />9- <br />C <br />O 0, U o <br />O • <br />0) On. (0 O <br />a) N <br />.0 Q (6 o, <br />CD(0 <br />• .o a) <br />O ..>,:-.) <br />.Q I- 0 <br />'to' a 3 c <br />cfC • a) ) aci t -o <br />a <br />>• O o T <br />0 o `o _c <br />0 CO <br />OD <br />m " o C6 C <br />c a •) U..,8 <br />U a) N •co <br />_eac c co a) 0 <br />o ,o ( 0 m <br />-0 n <br />m a n � I- t. <br />c E o _cm Z <br />o U , 0 > <br />I- .E m 3 0 0 co <br />CONTRACTOR'S APPLICATION FOR PAYMENT <br />N <br />c <br />0 <br />U <br />a) <br />.0 <br />c <br />O <br />U <br />a) <br />C <br />0 <br />U <br />c <br />3 <br />0 <br />0 <br />t <br />0-0 <br />a) <br />U <br />as <br />• a3 <br />a) <br />m 0 <br />E r) <br />•9 c <br />c 2 <br />o , <br />to <br />U ,C <br />no <br />Q 0 <br />RJM C <br />0 <br />0 0 <br />0 (0 <br />O <br />m 0 -a <br />N <br />a) <br />E <br />Q5) <br />0 <br />a) <br />.0 <br />0 <br />1..! <br />().co <br />%...o aE <br />E <br />0 Z' O <br />a) co (o 0 <br />U) U) Z <br />0115 <br />L <br />a o C) U o <br />O m 'Cr. <br />C @ -0 <br />C <br />O o a 0 c C 0 <br />fa o m a as <br />O ..N_. <br />a) o <br />Q) <br />O) Q im-, <br />O Q O = m <br />o n o c <br />0 <br />0 m 0 o f <br />0 <br />c 0 L <br />o <br />m <br />OC co O coQ O <br />-0-V 0 •Z <br />CD a) a) U <br />m o. a) w� o 0) <br />co <br />(Y aa) m <br />a `-3W� <br />E-( o a) U �-' r- • a 0 o m 2 z 0 (Mo L. <br />o <br />I-u <br />c' G' O `O O 1-- O) a) -Sr <br />0 .0 •2 U Q rr o <br />(O E m Q U_ E I <br />• ai <br />o•Qo �.._.--0coL� � <br />U n,c n <br />C O O y 0 O <br />23 <br />o a) o a 1- o <br />c Y O W 0_o <br />▪ � a0 <br />O .) m = <br />O c <br />m E0 L oa1 aU am0 <br />c 0 QQQ mQ.., <br />O O O N O CV CO <br />O O O O O O 00 <br />1` O ti O CV o0 '51- <br />00 co- 00 'mot o) 'ct' 00 <br />O O 00 O) co N <br />O 07 0) GO N (0 <br />O CO- M_ Ef} CO CO <br />(0 <br />CO H} EA 69- <br />E <br />O <br />0 <br />(o <br />c <br />O <br />0 <br />m <br />.0) <br />0 <br />a`) <br />0 <br />0) <br />OD <br />.0 0 <br />0 o <br />>, I- <br />E <br />CD <br />CO o <br />0 • ca <br />a) 0 <br />Z 0 <br />N <br />4. Total Completed and Stored To Date <br />O O <br />O O <br />0) O <br />0) 69 <br />0) <br />cri <br />EH <br />`o ▪ m <br />73 ▪ as <br />a) <br />n o <br />o <br />0 (O <br />0 0 <br />6. Total Earned Less Retainage <br />7. Less Previous Certificates For Payments <br />r <br />(o <br />O <br />o) <br />V' <br />Ef} <br />8. Current Payment Due <br />M <br />a0 <br />co <br />ti <br />1- <br />Es <br />9. Balance To Finish, Plus Retainage <br />W <br />1- <br />ce <br />Q <br />m <br />Deductions <br />O <br />0 <br />O <br />O <br />O <br />O <br />EA <br />EA <br />EA <br />O <br />0 <br />0 <br />O <br />O <br />O <br />O <br />O <br />Cj <br />0 <br />C <br />ER <br />Ef3 <br />69 <br />EA <br />0 <br />Q <br />CHANGE ORDER SUMMARY <br />Total changes approved <br />in previous months by Uwner <br />Total Approved this Month <br />TOTALS <br />Net Changes By Change Order <br />IEI <br />