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. AppDcatlon for Payment(continued) <br /> Total Contract Amount $ 6,671,414.00 Total Amount Earned $ 505552088 <br /> Material Suitably Stared on Site, Not <br /> Incorporated into Work <br /> Contract Change Order No. Percent Complete <br /> Contract Change Order No. Percent Complete <br /> Contract Change Order No. Percent Complete <br /> Less Previous Applications: -------' GROSS AMOUNT DUE <br /> -------- $ 5,055,520.88 <br /> ApP No. 1: 735`69078 xFPNo.o: LESS 5 96 RETAINAGE $ 252.776.04 <br /> AFp No.2: 2`136'706.33 AFpmm'r� AMOUNT $ 4802.744.84 <br /> AFp No. 3: 1.234.000.14 Appwua� LESS PREVIOUS APPLICATIONS $ 4108`39725 <br /> AFP No.4� AFpmo.o: AK�DUNTDUE THIS APPLICATION $ 688,34759 <br /> ----------` ---------' <br /> ApP No. 5., <br /> CONTRACTOR'S AFFIDAVIT <br /> The undersigned Contractor hereby swears under penalty of perjury that (1)all previous progress payments received from the <br /> Owner on account of work performed under the Contract referred to above have been applied by the undersigned to discharge <br /> in full all obligations of the undersigned incurred in connection v,11th work covered by prior Application5 for <br /> Payment Linder said contract, Water Treatment Plant Trunk Water Main Improvements, City of Ramsey, MN and(2)all <br /> material and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment and free <br /> and clear uf all liens, claims, security interests and encumbrances. <br /> /l«7 <br /> Date / . 2O Northde/a Construction Co . Inc. <br /> ` <br /> COUNTY OF By — Ld,, 1, <br /> STATE OF M1 n1J1461 >S8 ' (Name and TNm) <br /> Befyre me on thi 146day of Je . 20 personally appeared <br /> y PJ)/, J 57'0_,,�L kno%,yn to be, who being duly sworn did depose and say <br /> that4ieia the (office)AW2 Q�c <br /> oy the Contractor above mentioned that he executed the above <br /> Application for PuymnntaId'�Affidayi1on beMe(Yof said Contractor, and that all of the statements contained therein are trum, <br /> oonoot and <br /> SHEILA <br /> My Commiss Notary Public <br /> IL Minnesota _ft)tary Public) <br /> My Commission Expires <br /> The undmrsi lication for Payment shown above A part of this Application is the <br /> Contractor's Affidavit stating that all previous payments to him under this contract have been applied by him to discharge in full <br /> all of his obligations in connecting with the work by all prior Applications for Payment. <br /> In accordance with the Contract, the undersigned recommends approval of payment to the Contractor for the Amount due. <br /> City o/Ramsey, MN Short Elliott Hendrickson <br /> -,f By By <br /> Dave Hutton, PE (Lic. MN.ND,WO <br /> Oeto ������ '��^~� Date 8/14/24 <br /> Page 4or* <br />