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r <br /> t <br /> Contractor's Application for Payment <br /> Owner: City of Ramsey Owner's Project No,: 20-05 <br /> Engineer: Bolton&Menk,Inc. Engineer's Project No,: 0111.12590%OR1.128236 <br /> Contractor: Douglas-Kerr Underground,LLC Agency's Project No,: SP 020-121,SAP 119-115-005 <br /> Project: 2022 Riverdale Drive Extension <br /> Contract: <br /> Application No.: 6 Application Date: 9/26/2023 <br /> Application Period: From 6/6/2023 to 9/26/2023 <br /> 1 Or <br /> iginal anal Contract <br /> Price 2 421Q2.66; . <br /> 2. Net change by Ch <br /> ange a Orders <br /> 1 <br /> 3. Current i urr nt Contract +ra t Price(Line <br /> r �n 1 Line 2 <br /> � j 42,�02.6 <br /> 4. Total Work completed and materials stored to date <br /> (Sum of Column H Unit Price Total and Column M Stored Materials) $ 2255,068.29 e <br /> 5. Retainage <br /> a. X ..$... .2�55 068.2.9. Work Completed <br /> x <br /> Stored to 'Ma r�als <br /> l <br /> c. Total Retainsg a(Line 5.a+Line 5.b <br /> $ s <br /> 6. Amount eligible to date(Line 4-Line 5.c 55 0$... i........i...... ., <br /> 7. Less payments <br /> previous a <br /> P P Y $ 2126 032.64 <br /> 8. Amount due this application <br /> $ 129035s5.. <br /> 9. Balance to finish includingretains a Line 3-Line 4 <br /> g NA <br /> Contractor's FINAL PAYMENT 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 account to <br /> discharge Contractor's legitimate obligations incurred in connection with theWork co <br /> vered by prior Applications for 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 to Owner at time of payment free and clear of all liens,security interests,and encumbrances(except such as are <br /> covered by a bond acceptable to 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,and <br /> (4)The provisions of M.S.290.92 have been complied with and that all claims against me by reason of the Contract have been paid or t <br /> satisfactorily secured. <br /> Contractor: <br /> is <br /> Signature: _• Date: <br /> Name: Title: <br /> s- <br /> f <br /> Recommended by Engineer Approved by Owner <br /> By: By: <br /> Name: Kevin P.Kielb <br /> Name; � ` <br /> Title: Project Engineer Title. <br /> Date: 9/26/2023 Date: <br /> EJCDC C-620 Contractor's Application for Payment <br /> (c)2018 National Society of Professional Engineers for EJCDC. All rights reserved. `' <br />