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Contractor's Application for Payment wner: City of Ramsey owner's Project No.: 23-12 <br /> Engineer: Bolton&Menk,Inc. Engineer's Project No.: 0111.126299 <br /> Contractor: Douglas-Kerr-Underground,LLC Agency's Project No.: <br /> Project: HY-16 Ramsey improvements <br /> Contract: <br /> Application No.: 4 Application Date: 11 2/2 <br /> D23 <br /> � <br /> Application Period: From 10/1/2023 to 10/31/2023 <br /> 1. Original Contract Price $ .113981953.30 <br /> 2. Net change by Change Orders $ <br /> ....nrr..�wrrr_n i i u in i r.n_.nnnnuun_r.oinimn.�r.mno�un.r_u..nn.r_rrrw......r <br /> 3, Current Contract Price(Line 1+Line 2) $ 1,398,953.30 <br /> 4. Total Work completed and materials stored to date _......._.�.. <br /> (Sum of Column O Lump Sum Total and Column J Unit Price Total) $ 1,390,164.83 <br /> 5. Reta inage <br /> a. 1/ k $ 1,390,164.83 Work Completed $ 13,901.65 <br /> n.nnnnimr..rrrr+r..iwiiq.oionnnn.i�rrr...r.ry <br /> b. x $ - Stored Materials $ <br /> c, Total Retainage(Line 5.a+Line 5.b) $ 13 901.65 <br /> 6. Amount eligible to date(Line 4-Line 5.c) $ 1,376 263.18 <br /> 7. Less previous payments $ 10200,270.12 <br /> 8. Amount due this application 175, 93.06 <br /> 9. Balance to finish, including retainage(Line 3 Line 4) $ 817 <br /> , 47 � <br /> Contractor's Certification <br /> I <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 <br /> 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 /> y£F, <br /> I <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 <br /> are 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. <br /> �J. <br /> Contractor. <br /> Signature: <br /> Date: <br /> Name: <br /> Title: . <br /> Recommended by Engineer Approved by Owner <br /> l <br /> By. B . <br /> yi !.• <br /> .Name: Zach Lingl,P Name: <br /> LA L <br /> F' <br /> Title: Project Manager Title: � <br /> Date: 11/3/2023 Date: <br /> 3 <br /> EJCDC C-620 Contractor's Application for Payment <br /> (c)2018 National Society of Professional Engineers for EJCDC. All rights reserved. '= <br />