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Total Contract Amount <br />Contract Change Order No. <br />Contract Change Order No. <br />Contract Change Order No. <br />Less Previous Applications: <br />AFP No. 1: $735.690.78 <br />AFP No. 2: <br />AFP No, 3: <br />AFP No. 4: <br />AFP No. 5: <br />$2.136,706.33 <br />$1,234,000.14 <br />$698,347.59 <br />$ 6,671,414.00 <br />AFP No. 6. <br />AFP No. 7: <br />AFP No. 8: <br />AFP No. 9: <br />Application for Payment (continued) <br />Total Amount Earned <br />Material Suitably Stored on Site, Not <br />Incorporated into Work <br />Percent Complete <br />Percent Complete <br />Percent Complete <br />GROSS AMOUNT DUE <br />LESS 5 % RETAINAGE <br />AMOUNT DUE TO DATE <br />LESS PREVIOUS APPLICATIONS <br />AMOUNT DUE THIS APPLICATION <br />$ 5,977,806.12 <br />$ 5,977,806.12 <br />298,890.31 <br />$ 5,678,915.81 <br />$ 4,802,744.84 <br />876,170.98 <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 with work covered by prior Applications for <br />Payment under 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 of all liens, claims, security interests and encumbrances. <br />Date <br />COUNTY OF <br />STATE OF <br />oc1/17 <br />WJ'LL IT/ <br />Before me on this day of <br />that he is the <br />, 20 <br />) SS <br />By <br />Northdale Construction Co., Inc.. <br />(Contractor) <br />Lr (7(e c firiirt. Prof fWan ttger <br />(Name and Title) <br />204' personally appeared <br />known to be, who being duly sworn did depose and say <br />iTt .0office) of the Contractor above mentioned that he executed the above <br />Application for Payment and Aff avit on beha of said Contractor; and that all of the statements contained therein are true, <br />correct and complete. <br />My Commission expires <br />Public) <br />The undersigned has the ntractoa yment shown above. A part of this Application is the <br />Contractors Affidavit stati p y ents 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 />SHEILA J GOEB <br />Notary Public <br />Minnesota <br />My Commission Expires <br />I <br />In accordance with the Contract, the undersigned recommends approval of payment to the Contractor for the Amount due. <br />City of Ramsey, MN <br />By_if <br />Date <br />Short Elliott Hendrickson Inc. <br />By <br />Dave Hutton, PE (Lic. MN, ND, WI) <br />Date 9/16/2024 <br />Page 4 of 4 <br />