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Contractor's Application for Payment <br />Owner: City of Ramsey Owner's Project No.: CP# 21-00 <br />Engineer: Bolton & Menk, Inc. Engineer's Project No.: 0R1.124017 <br />Contractor: Kuechle Underground, Inc. Agency's Project No.: SAP 199-108-044 <br />Project: Riverdale Drive Improvements <br />Contract: <br />Application No.: 1 Application Date: 5/4/2021 <br />Application Period: From <br />4/1/2021 to - 4/30/2021 <br />1. Original Contract Price <br />2. Net change by Change Orders <br />3. Current Contract Price (Line 1 + Line 2) <br />4. Total Work completed and materials stored to date <br />(Sum of Column G Lump Sum Total and Column J Unit Price Total) <br />5. Retainage <br />a. 5% X , $ : 52,145.00 Work Completed <br />Stored Materials <br />c. Total Retainage (Line 5.a + Line 5.b) <br />6. Amount eligible to date (Line 4- Line 5.c) <br />7. Less previous payments (Line 6 from prior application) <br />8. Amount due this application <br />9. Balance to finish, including retainage (Line 3 - Line 4) <br />771,913.13 <br />771,913.13 <br />52 145.00 <br />2,607.25. <br />2,60725 <br />49,537.75 <br />49,537.75 <br />719,768.13 <br />Contractor's Certification <br />The undersigned Contractor certifies, to the best of its knowledge, the following: <br />(1) All previous progress payments received from Owner on account of Work done under the Contract have been applied on <br />account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for <br />Payment; <br />(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in or covered by this Application for <br />Payment, will pass t❑ Owner at time of payment free and clear of all liens, security interests, and encumbrances (except such as <br />are covered by a bond acceptable t❑ Owner indemnifying Owner against any such liens, security interest, or encumbrances); and <br />(3) All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. <br />Contractor: Kuechle Underground, Inc. <br />Signature: <br />Name: <br />( <br />David J. Baker <br />Date: <br />Title:. <br />04 May, 2019 <br />Project Manager <br />Recommends by Engineer <br />. w <br />y: <br />Name: Kevin Kielb <br />Title: Project Engineer <br />Date: 5/4/2021 <br />Approved by Owner (City of Ramsey) <br />By: . -- • �' <br />Name: <br />Title: <br />Date: <br />12- ‘7.___( <br />—r-1-", LC)e—C;-R-J <br />Efrt.'AilQ <br />EJCDC C 620 Contractor's Application for Payment <br />(c) 2018 National Society of Professional Engineers for EJCDC. All rights reserved. <br />