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Total Contract AnIoLint $ 6o6710414tOO <br />r-.rac:1 Change Order Not <br />Goiitract Change Order No.. <br />Contract Change Order No. <br />C;ontracl Change Order No. <br />. $130`.''. <br />' $14 F1 1608*93 <br />3--24,765-h45 <br />�-_ <br />. S881998,3 7 <br />Total Contract with Chabge Orders $71156,,903.13 <br />ApplIcation for Payment (contklued) <br />Less Previous Applications: <br />AFP NO F 1 $7351690*78. <br />AFP No, 2: $2,136,706.33 <br />-- <br />_F^No. c $112340000-14 <br />AFP No. 4-11 $6961347.59 <br />..1_ <br />AFP No, 5., $876w,170II,98 <br />_ <br />Total Amount Earned <br />Material Sultably Gtored on Site, Not <br />Incorporated into Work <br />Perce.nt Coniplete <br />percent Complete <br />Percent Complete <br />Percent Coniplete <br />GROSS AMOUNT DUE <br />LESS ^ ~=E'-'^'E <br />AMOUNT DUE TO DATE <br />LESS PREVIOUS APPLICATIONS <br />AMOUNT DUE THIS APPLICATION <br />__ <br />_ <br />_ <br />6-P6381394 028 <br />.'_- 1 -_ __-. <br />� `.��.9_- <br />.'_.. __ <br />6130 61474 t. 5 6 <br />-.' <br />| 5-16781915.81 <br />-_ <br />-............. <br />__.' . <br />627,558.75 <br />CONTRACTOR'tS AFFIDAVIT <br />The Undersigned Contfactor hereby swears under penally of perjui-y that (1) all previous progress payrilents received frorn theed`_`e <br />Owner on account of'Work perfornied under [lie Contract referred to above have, 'en ap.r'.the ''crs'ig`ed`'sc--ge` <br />full all obligations of the undersigned incurred in conneeflon with work covered by prior Applications for <br />PaynIC11t Under said contract, Water Treatment Plant -._ Water Main ..ro.`'n', City of Ramsey, MN and (2) all ni,'` <br />and equipment Incorporated ` said Project `' otherwise Usted.c.covered '` this Application for P.'.._'and free and clear , <br />all liens, claims, security interests and e.Ul_'..-css. <br />' <br />I k <br />COUNTY OF <br />STATE OF <br />-__ <br />- <br />' <br />Northdale Construction Co., Inc, <br />(C oil tra cto r <br />(Narne and Title <br />`ffice~. C'.���^.o`e .�.e'.-._'e.e'-ed.yab..e,p��r�.��------'for Payment pnd AffiLdayft on"'-ehaff of ��.e,a�'=~�`^',�e'��`-^��``+'*��'`' <br />dayr . . '��"''��`''-``'^ -- <br />'_ that <br />CD .~'. . __ '_`k110'Nn,.='`oz'._'-.s`.'`'�d`.ose and �'`__ <br />he �.a ``_.`.�� ' ' A\ CLr) i:lt. <br />c'.."`, <br />My Conimission expires <br />KRISTINE R CHRISTENSON <br />Notary Pubi <br />Ic <br />Minnesota <br />My Commission Expires <br />Jan 31 2029 <br />(Notary Public) <br />The ..z��s'.� the ContraAppl'ication - Payment ro.e�~`-._�,z``r�'�]��-�'� <br />Affidav'it stating that all prev'lous paym,enls to him under this contract have been applied by hirn to discharge in full all ofhis <br />obligations 'in zc),`"".with the work '' all prior Applications for Payment. <br />In accordance with the Contract, the undersigned recommends al)proval o'_`.r.the Contractor for the Amount due. <br />Short Efflatt Hendricksoll Inc. <br />City of RanisoyMN <br />By <br />By <br />' <br />Dave Hutton, PE (Lic. MN, N <br />�`te,_ _ 10/ -1012 0 24_. <br />VVI) <br />- <br />- <br />- <br />Page 4 of 4 <br />