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APPLICATION FOR PAYMENT <br />Application No: <br />Project: •City of Ramsey Public Works <br />E <br />2 <br />H LL <br />19520-0180 <br />O <br />N <br />M <br />N <br />0 <br />O <br />Contract Date: <br />195200180-033005 <br />Commitment: <br />Contract For: 195200180-033005 - Concrete <br />0 <br />N -4 O <br />0.L• <br />n• E <br />U U 0 <br />as3 <br />a i 0 a <br />0 m x c <br />O 1 °. <br />0 <br />m o. o` <br />V a7 <br />O2 <br />O OE <br />O <br />c �U,k <br />a o a <br />tli L m <br />.0c> <br />L U <br />o �v d <br />T O C <br />0 o c E <br />ma � <br />T <br />� N woo. <br />i <br />N .0 co <br />C <br />-mU«o <br />a <br />noai <br />ma¢ E ya <br />U 2 @ 30 <br />T N C <br />ua o 3 w <br />.cELIU.5aci.5 <br />pp 2 <br />'A N aN .c <br />c <br />g <br />OI O UO •.- o <br />m <br />0 N G E <br />F.00 0 U o. <br />$1,347,350.00 <br />1. ORIGINAL CONTRACT AMOUNT <br />O <br />O <br />O <br />2. NET CHANGE BY CHANGE ORDERS <br />O <br />O <br />M <br />N. <br />M <br />3. CONTRACT SUM TO DATE <br />4.' <br />0 <br />O <br />1- <br />Z <br />000 <br />O <br />N <br />0 <br />r <br />N <br />O <br />rn <br />0 <br />m <br />O <br />O <br />O <br />O <br />O <br />O <br />4. TOTAL COMPLETED AND STORED TO DATE <br />E <br />0 <br />U <br />0 <br />w <br />5. RETAINAGE <br />4-4 <br />0 <br />C <br />0 <br />5.00% of Completed Work <br />0 <br />m <br />Subscribed and sworn to before me this <br />(Columns D + E) <br />0 <br />O <br />Z <br />5.00% of Stored Materials <br />My commission expires: <br />LL <br />c <br />E <br />0 <br />U <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />O <br />O <br />O <br />O <br />O <br />Total Retainage <br />(Line 5a + Line 5b OR Sum of Column I) <br />_N N <br />U O <br />r m ro <br />O U <br />'O :CPU <br />o <br />Ya)0 <br />o <br />cou- LAL <br />co" <br />yo�oi8.c <br />O <br />C Q N W <br />0.a c L c <br />No m <br />+' c <br />N O <br />oyUo <br />IT, <br />0 0 <br />$ra0 <br />c o m o <br />O y Y <br />V N t_ <br />.O U.S W <br />U IL <br />a�o <br />.c fY <br />o W <br />� ,o.at8U <br />O a> cZ <br />N y. 0 <br />C tea) El <br />c <br />(3 . <br />aoo <br />E a <br />3 r E <br />o <br />U C) C a) NT <br />ac'y§ mOo '0 <br />pafaY <br />ECCU .c.ac <br />6. TOTAL EARNED LESS RETAINAGE <br />(Line 4 less Line 5 Total) <br />O <br />O <br />7. LESS PRIOR CERTIFICATES FOR PAYMENT <br />(Line 6 from prior Certificate) <br />O C <br />o m <br />0 w <br />ToTo o <br />a o <br />= U <br />0 N <br />m m <br />M. 0 <br />(0 0 <br />c <br />o to <br />o m <br />0 <br />y <br />o0 <br />8. CURRENT PAYMENT DUE <br />$1,214,350.00 <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />ARCHITEC <br />(Line 3 less Line 6) <br />N <br />a3 <br />0 <br />0 <br />DEDUCTIONS <br />co <br />O <br />$0.00 <br />O <br />69 <br />SNOLLIaad <br />0 <br />O <br />O <br />ER <br />0 <br />O <br />O <br />E9- <br />$0.00 <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 />