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in 0 <br />kn 6 <br />CD <br />c5 <br />Oo 41 <br />Envelope ID: 74A66727-20DF-4329-9253-19EDEA1C9B7F <br />APPLICATION FOR PAYMENT <br />O 0 <br />'-- M <br />0 0 <br />r r r <br />Application No <br />Project: City of Ramsey Public Works <br />Application Date: <br />19520-0180 <br />Contract Date: <br />195200180-030105 <br />Commitment: <br />Contract For: 195200180-030105 - Masonry <br />�Lm� <br />R1 <br />c L � <br />U U_ B <br />O c L O <br />cv3m <br />• w <br />.0 N O 0 0 <br />07 C <br />�tocmoc <br />0 3 <br />0) ao0 <br />s <br />o E <br />a 0U,0 <br />•0 a) v <br />0) nL a) <br />O C •O N <br />0) 01 <br />.0 (TO C 0) <br />a)a m <br />5a.Dj' <br />a 0) o. <br />m .0 c <br />00 07 <br />0 , G V <br />• a= F, S <br />m < E'N a <br />0 y m� <br />o Tm 0) <br />5onmN <br />c E C• <br />'88. <br />0 <br />N ( N <br />m•0 o m <br />,nUU am <br />O <br />O <br />O <br />N <br />(0) <br />N <br />Eft <br />1. ORIGINAL CONTRACT AMOUNT <br />O <br />O <br />O <br />2. NET CHANGE BY CHANGE ORDERS <br />O <br />O <br />0 <br />N <br />('7 <br />N <br />Eft <br />3. CONTRACT SUM TO DATE <br />CONTRACTOR: <br />4. TOTAL COMPLETED AND STORED TO DATE <br />0) <br />(0 <br />❑ <br />0 <br />0) <br />m <br />m in <br />C7 <br />c <br />E <br />0 <br />U <br />5. RETAINAGE <br />_ <br />0 <br />0 <br />5.00% of Completed Work <br />4- <br />0 <br />m <br />a <br />Subscribed and swom to before me this <br />(Columns D + E) <br />0 <br />.O <br />0 <br />Z <br />5.00% of Stored Materials <br />My commission expires: <br />LL <br />c <br />E <br />3 <br />0 <br />0 <br />ARCHITECTS CERTIFICATE FOR PAYMENT <br />Total Retainage <br />I^ N <br />a> O <br />0 Q N O <br />0) <br />m y <br />0oL <br />N y a's <br />c 2 0) 0) <br />O m <br />..00.c4 <br />asr� c <br />oa)E <br />a m c <br />O N0 0 <br />0 <br />9 ❑ <br />o 0 <br />y5<0) 0 0 <br />U <br />5202 <br />m v • •0) <br />a m c 0 <br />O = � LL <br />«N, <br />c c 0 m F <br />=208U <br />8<0 0z c_ <br />▪ a) N O <br />c 8.o 0Q <br />c m <br />00)) 5 0 <br />0 E tl ; <br />35ov5. <br />tOI C .� 0) W <br />•N 0a <br />N <br />✓ Egli o <br />8 • d <br />o E o <br />O 8. G 0) <br />(Line 5a + Line 5b OR Sum of Column I) <br />(() <br />CV <br />M <br />0. <br />N <br />Eft <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 />U7 <br />C1 <br />(Y) <br />O <br />N <br />Eft <br />8. CURRENT PAYMENT DUE <br />9. BALANCE TO FINISH, INCLUDING RETAINAGE <br />N <br />N <br />O <br />r• <br />(Line 3 less Line 6) <br />0)) <br />0 <br />m <br />E d <br />c <br />to a <br />0 p) <br />Uc <br />T <br />DEDUCTIONS <br />0 <br />0 <br />0 <br />0 <br />O <br />O <br />0 <br />O <br />O <br />Eft <br />O <br />Eft <br />O <br />E9 <br />O <br />es- <br />0 <br />O <br />0 <br />O <br />O <br />O <br />Z <br />Eft <br />Eft <br />Eft <br />0 <br />1, <br />a <br />0 <br />d <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 />