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Contractor's Application for Payment <br /> Owner: City of Ramsey Owner's Project No.: 23-04 <br /> Engineer: Bolton&Menk,Inc. Engineer's Project No.: 0R1.129245/0R1,131249 <br /> Contractor: Asphalt Surface Technologies Corp. <br /> Agency's Project No.: <br /> Project: SAP 199-102-007167th Avenue Reconstruction <br /> Contract: <br /> Application No.: 2 Application Date: 11/13/2023 <br /> Application Period: From 10/1/2023 to 10/31/2023 <br /> 1. Original Contract Price <br /> g . <br /> � a59 <br /> 2. Net change <br /> bYhg <br /> Change Or <br /> ders <br /> rd ers <br /> 3. Current Contract Price Line 1+Line 2 <br /> � ) <br /> :......:.... <br /> 4. Total Work completed and materials stored to date <br /> [Sum a f Column G Lump Sum Total and Co <br /> lumn�Unit Price Total) <br /> tal <br /> ;. <br /> S. Retainage <br /> ......:::. <br /> a <br /> . a <br /> i' }{ 1 12 :. <br /> 34 7 3 1111O r�. .. � a l, k Completed 22 <br /> .......:...... <br /> f <br /> ..:.......... <br /> ..::...:::..:...... <br /> ......:.:..:: <br /> b. <br /> x <br /> Stored ate M ra� IS <br /> c. Total Retainage(Line 5.a+Line 5.b) <br /> b. Amount elig <br /> ib <br /> le to date(Li <br /> ne e 4 Li <br /> ne 5.c 2. <br /> ...... .... <br /> .3�2 57nnaQQ <br /> 9.'7. Lessprevious paY e is ".-. <br /> V. Amo Amount due this Asa appl <br /> ication n <br /> t <br /> Q <br /> ,r _ <br /> 9. Balance to including retai a eL(Line 3- Line 4 <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 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 /> f <br /> Contractor: <br /> Signature: date: ` <br /> o <br /> Name: 00000ir,, Title: <br /> Recommended b Engineer Approved by Owner <br /> f <br /> y: By: F <br /> Name: 2ach Lingl, E Name: <br /> Title: Project Manager Title: <br /> Date: 11/13/2023 Date: <br /> LJCDC C-620 Contractor's Application for Payment <br /> (c)2018 National Society of Professional Engineers for EJCDC. All rights reserved, <br /> i <br />