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z Contractor's Application for Final Payment Owner: Cite of Ramsey Owner's Project No.: 23-04 Engineer: Bolton&Menk,Inc. Engineer's Project No.: 0111.129245/oR1.131249 Contractor: Asphalt Surface Technologies Corp. Agency's Project No.: Project: SAP 199-102-007157th Avenue Reconstruction Contract: Application No.: 3-FINAL Application Date: 8/19/2024 Application Period: From 11/1/2023 to 8/1/2024 1. Original Contract Price $ 1,51�.,455.59 2. Net change by Change Orders $ _ 3. Current Contract Price(Line 1+Line 2) $ 11511,.455,59 4. Total Work completed and materials stared to date (Sum of Column G Lump Sum Total and Column J Unit Price Total) $ 1,347,843.87 5. beta i n age a. X $ 1,347,843.87 Work Completed $ A b. X - Stored Materials $ - c. Total 1•etalnage(Line 5.a • Fine 5.b) $ 6. Amount eligible to date(Line 4--Line 5,c) $ If 347j,843.87 7. Less previous payments $ 1,327,815.10 8, Amount due this application 20,028,77 9. Balance to finish,Including retainage(Line 3-Line 4) NA Contractor's Certification for Final Payment The undersigned Contractor certifies,to the beet of its knowledge,the following: (1)All previous progress payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for Payment; (2)Title to all Work,materials and equipment incorporated in said Work,or otherwise listed in or cowered by this Application for Payment,will pass to Owner at time of payment free and clear of all liens,security interests,and encumbrances(except such as are covered by a bond acceptable to Owner indemnifying Owner against any such liens,security interest,or encumbrances);and (3)All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective;and (4)The provisions of M.S.290.92 have been complied with and that all claims against me by reason of the Contract have been paid or satisfactorily secured. Contractor: Asphalt Surface Technologies Corporation Signature: - Date: 2 2024 Name: Jessica L. Winter Title: Vice—Presid ent Recommended by Engineer Approved by Owner By. By. Name: Zach Lingl,P Name: ,: , ..s b .�.�...., +, .wll Title: Project.Manager Title: + � t�r•..c .� z %J Date. B/ 9/20Z4 Date: 11 ?V-X. I z-=-Z. EJCDC C-620 Contractor's Application for Payment (c)2018 National Society of Professional Engineers for EJCDC, All rights reserved.