Agenda - Council - 10/24/2023 - Laserfiche WebLink

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Contractor's Application for Payment Owner. City of Ramsey owner's Project No.: 23-44 Engineer: Bolton&Menk,Inc. Engineer's Pro ect No.: DR1.129245/0R1,13 .249 Contractor: Asphalt Surface Technologies Corp. Agency's Project No.: Project: SAP 199--102-007157th Avenue Reconstruction Contract: Application No.: 1 Application Date: 14/9/2023 Application Period: From 8/21/2023 to 10/1/2023 1 3:1-455'59, 1. Original Contract Price 2. Net change by Change orders 5 . 145 9. .5 3, Current Contract Price(Line 1+Line 2) 1,.5 .. . 4. Total Work completed and materials stored to date �9 548'4 '. 3 r (Sum of Column G Lump Sum Total and Column J Unit Price Total) 5, Retainage 7:7.. 2 ' v x 339 548 1Nork Cam fete .1S 9 4 a. 5r $ P l b, }� $` Stared Materials � • 16 9742 c. Total Retainage(Line 5.a+Line 5.16) 5. Amount eligible to date(Line 4-Line 5.c) .. ..:...........:.................... ......... .. 32 5 �. 99,� 1 -- :. 7. Less previous payments a m enis ' 2 57 .0 99 pp . 8. Amount due this application ` 3 2 9. Balance to finish,Including retalnage(Line 3 Line 4) w 37 �07.18 . F Contractor's Certification The undersigned Contractor certifies,to the best of its knowledge,the following: (J.)Ail previous progress payments received from Owner on account of Work done under the Contract have been applied on obligations incurred In connection with the Work coveted by prior Applications for 1 account to discharge Contractor's legitimate g ,. 3. Payment; 2 Title to all Work,materials and equipment incorporated in said work,or otherwise listed In or covered by this Application for p,Payment,will ass to Owner at time of payment free and clear of all liens,security interests,and encumbrances{except such as Y a are covered by a bond acceptable to Owner Indemnifying Owner against any such liens,security interest,or encumbrances};and (3)All the work covered by this Application for Payment is in accordance with the Contract Documents and is not defective. AA i 1 r Contractor: ` Y Signature: F Date: /0 .3 F Name: Title: eff l Recommended by Engineer Approved by owner j I By: By: Name: 2ach Ling,P Name; Q-4--1 C�-- • Title: Title: Project Manager = r Iry s Date: 10/13/2023 Date. 3 EJCDC C-620 Contractor's Application for Payment 4c;2018 Natlonll Society of Professional Engineers for EJCDC. All rights reserved.